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BOOK 6 18. 92. K
KERLEY n TREA
CHILDREN
3 TIS?
TREATMENT
DISEASES OF CHILDREN
BY
CHARLES GILMORE KERLEY, M.D.
PROFESSOR OF DISEASES OF CHILDREN, NEW YORK POLYCLINIC MEDICAL SCHOOL
AND hospital; ATTENDING PHYSICIAN TO THE NEW YORK INFANT ASYLUM;
ATTENDING PHYSICIAN FOR CHILDREN, SYDENHAM HOSPITAL, NEW YORK ;
ASSISTANT ATTENDING PHYSICIAN TO THE BABIES' HOSPITAL, NEW
YORK ; PRESIDENT OF THE AMERICAN PEDIATRIC SOCIETY, ETC.
FULLY ILLUSTRATED
PHILADELPHIA AND LONDON
W. B. SAUNDERS COMPANY
1907
Copjoight, 1907, by W. B. Saunders Company
TO
MY PRACTITIONER STUDENTS
PAST AND PRESENT
NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL,
AT WHOSE SUGGESTION
THIS WORK HAS BEEN PREPARED
PREFACE
This work has been prepared for the general practitioner of
medicine. It has not been written with a view to supplying the
needs of either the specialist in children's diseases or the under-
graduate student. The possibilities of therapeutic measures in the
treatment of children have greatly increased during the past decade ;
and the author's effort in this volume has been to present to the
physician in active general practice, modern methods of management
in greater detail than has been attempted by the valuable books
already on the market. The means and methods suggested herein
are not drawn from the Hterature, but from experience based upon a
somewhat extensive appHcation of the. principles evolved by the
author in private and hospital practice. This book is offered, there-
fore, with the hope that it may be of service to other physicians in
caring for an important group of their patients.
The author wishes to acknowledge his indebtedness to Dr. James
F. McKernon for suggestions in the chapters on the diseases of the
ear; to Dr. Thomas L. Bennett for suggestions in the chapter on
Anesthetics; to Dr. N. Curtice Holt for the revision of the proof
sheets, and to Dr. Royal Storrs Haynes for the arrangement of the
index and his valuable assistance in the preparation of the chapter on
Drugs and Drug Dosage.
Charles Gilmore Kerley
New York,
CONTENTS
General Considerations 17
Therapeutics in Children 17— Clothing and Additional Requirements
for the Expected Baby, 19 — The Young Mother, 21 — The Nursery
laid, 22 — The Nursing-bottle and Nipple, 23 — The Nursery, 24
Baskets for Early Exercises, 25 — Care of Stump of Umbihcal Cord, 26 —
Crying, 26— Sleep, 27— Kissing, 28— Baths, 29— Weight, 31— Height, 34
— Teeth, 35 — Days to go Out of Doors; Indoor Airing, 36 — Exercise
Pen, 37 — First Examination of Patient, 39 — Written Directions, 39 —
Treatment of Individual, 41 — Necessity of Method in the Management
of Children, 42— The Sick-room, 43.
The New-born 45
Premature and Congenitally Weak Infants, 45 — Asphyxia, 48 — Sepsis,
49 — Cephalhematoma, 50 — Icterus Neonatorum, 50 — UmbiHcal Polypi
51 — Atelectasis, 51 — Mastitis, 52 — Umbilical Granuloma, 53 — Hemor-
I rhagic Diseases, 53 — Tetanus Neonatorum, 54.
'Nutrition and Growth 55
General Properties of Foods, 59 — Maternal Nursing, 62 — Wet-nurse,
73 — Human Milk, 75 — Cracked and Fissured Nipples, 77 — Caking of
the Breasts, 78 — Depressed Nipples, 79 — Acute and Suppurative Mas-
titis in the Mother, 79 — Substitute Breast-feeding, 80 — Artificial
Feeding, 80— Cow's Milk, 98— Cream, 107— Difficult Feeding Cases,
108 — Sterilization and Pasteurization of Milk, 111 — Condensed Milk,
114— Peptonized Milk, 115— Milk for Travehng, 116— The Proprietary
Foods, 117— Cereal Gruels, 1 19— Starch-feeding, 119— Food For-
mulas, 123 — Habitual Loss of Appetite, 125 — Common Errors in Feed-
ing, 127 — Diet from the First to the Sixth Year, 128 — Diet after the
Sixth Year, 132— How the Child Should be Fed, 132— Diet during
Illness, 133 — Gavage, 134 — Substitutes for Stomach-feeding, 138 —
The Delicate Child, 142 — Marasmus; Athrepsia; Infantile Atrophy,
150 — Malnutrition in Infants, 156 — Tardy Malnutrition, 158.
Gastro-enteric Diseases 160
Acute Intestinal Indigestion, 160 — Persistent Intestinal Indigestion,
161 — Persistent Intestinal Indigestion in Older Children, 162 — Colic,
164 — Bowel Function, 166 — Vomiting, 176 — Acute Gastritis and Acute
Gastric Indigestion, 177 — Chronic Gastric Indigestion; Chronic Gas-
tritis, 179 — Lavage; Stomach-washing, 180 — Dilatation of the vStom-
ach, 183 — Ulceration of the Stomach, 184 — Congenital Pyloric Steno-
sis, 185 — Prevention of Acute Intestinal Diseases of Summer, 186 —
Acute Gastro-enteric Infection ; Cholera Infantum ; Gastro-enteric
Intoxication, 191 — Acute Enteric Infection, 197 — Acute Ileocolitis,
199— Chronic IleocoUtis, 204 — Mucous Colitis, 206 — Colon Irrigation,
207 — Intestinal Obstruction, 209 — Appendicitis, 210 — Intussuscep-
tion, 211 — Inflammation of the Anus, 213 — Fissure of the Anus, 213 —
The Intestinal Parasites, 214 — Prolapse of the Anus and Rectum, 216 —
Ischiorectal Abscess, 218 — Hemorrhoids, 218 — Rectal Polypus, 219 —
Incontinence of Feces, 219.
The Mouth, Thro.a.t, and Nose 220
Stomatitis, 220 — Sprue, 223 — Thrush; Mycotic Stomatitis, 223 — Can-
crufn Oris; Noma, 224 — Bednar's Aphthae, 225 — Fissures of the Lips,
226 — Ulcerations and Fissures at the Angle of the Mouth, 226 — Ulcer
of the Frenum of the Tongue, 226 — Geographic Tongue, 227 — Tongue-
tie, 227.
14 CONTENTS
PAGE
Diseases of the Respiratory Tract 228
Taking Cold, 228— Acute Rhinitis (Coryza; Snuffles; Cold in the Head),
229 — Recurrent Coryza and Angina, 233 — Nasal Hemorrhage, 234 —
Throat Examination, 234 — Faucitis, 235 — Pharyngitis, 236 — Tonsillitis,
236 — Hypertrophied Tonsils, 239 — Peritonsillar Abscess; Quinsy, 240
— Retropharyngeal Abscess; Suppurative Retropharyngeal Adenitis,
242 — Retropharyngeal Abscess (Tuberculous) ; Caries of the Cervical
Vertebrae, 245 — Irrigation of the Throat, 245 — Acute Catarrhal Laryn-
gitis, Spasmodic Croup, 246 — Laryngismus Stridulus, 251 — Traumatic
Laryngitis, 253 — Laryngeal Obstruction, 254 — Foreign Bodies in the
Larynx, 254 — Persistent Cough, 255 — Bronchitis, 257 — Recurrent
Bronchitis, 261 — Bronchial Asthma, 263 — Bronchopneumonia; Catar-
rhal Pneumonia, 266 — Lobar Pneumonia, 272 — Primary Pleurisy, 278
— Secondary Pleurisy, 279 — Primary Tuberculous Pleurisy, 280 — Empy-
ema, 280 — Double Empyema, 284 — Empyema Necessitatis, 284 — Pul-
monary Tuberculosis 285 — Bronchiectasis, 287.
Diseases of the Heart 289
Pericarditis, 289 — Acute Endocarditis, 290 — Mahgnant Endocarditis,
293— Myocarditis, 293— Chronic Valvular Disease of the Heart, 296—
Congenital Heart Disease, 299 — Abuse of Heart Stimulants, 299.
Contagious Diseases 300
Care to be Exercised by the Physician in Visiting Contagious Diseases,
300 — Quarantine, 300— Diphtheria, 302 — Intubation, 310 — Scarlet
Fever, 314 — Whooping-cough; Pertussis, 321 — Measles, 330 — Chicken-
pox; Varicella, 332 — German Measles; Rubella, 333 — Mumps; Epi-
demic Parotitis, 334.
The Urine 335
Difficult and Painful Urination, 336 — Retention and Suppression of
Urine, 336 — Incontinence of Urine; Bed-wetting; Eneuresis, 338 —
Albuminuria, 342 — Acute Nephritis, 343 — Chronic Diffuse Nephritis,
348 — Glycosuria, 349 — Diabetes Insipidus; Polyuria, 350 — Diabetes
Mellitus, 350 — Vesical Calculus; Stone in the Bladder, 351 — Cystitis,
351— Acute Pyelitis, 352.
The Male Genitals 352
Phimosis, 353 — Paraphimosis, 353 — Balanitis, 354 — Circum.cision, 354 —
Gonorrhea in the Male, 355 — Orchitis, 355 — Hydrocele, 356 — Unde-
scended Testicle, 356.
The Fem.\le Genitals 357
Simple \'ulvovaginitis, 357 — Gonorrheal Vulvovaginitis, 357.
Nervous Disorders 359
Headache, 359 — Hysteria, 359 — Infantile Convulsions, 363 — Night-
terrors, 365 — Gyrospasm; Spasmus Nutans, 365 — Tetany, 366 —
Chorea; St. Vitus' Dance, 367 — Habit Spasm, 370 — Epilepsy, 371 —
Meningitis, 373 — Lumbar Puncture, 376 — Chronic Internal Hydroceph-
alus, 377 — Acute Anterior Poliomyelitis; Infantile Paralysis, 378 —
Diphtheritic Paralysis, 379 — Multiple Neuritis, 381 — Facial Paralysis,
382— Cerebral Palsies, 383— Idiocy, 384— Erb's Palsy; Obstetric Par-
alysis, 386 — Hiccough, 387 — Angioneurotic Edema, 387.
Syphilis 389
Primary Congenital Syphilis, 389 — Tardy Hereditary Syphilis, 391 —
Tardy Malnutrition of Syphilitic Origin, 392.
Deformities 395
Inguinal Hernia, 395— Umbilical Hernia, 396— Ventral Hernia, 397—
Spina Bifida, 397 — Harelip, 398 — Hematoma of the Sternocleidomas-
toid Muscle, 398— Cleft Palate, 398.
Diseases of the Skin 400
Eczema, 400 — Urticaria; Hives; Nettle-rash, 407 — Impetigo Conta-
giosa, 408 — Pemphigus, 408— Erythema Nodosum, 409 — Erythema
Multiforme, 410 — Rhus Poisoning; Ivy Poison, 410 — Furunculosis ;
Boils, 411— Scabies; Itch, 412— Bed-sores; Decubitus, 413— Pediculi,
CONTENTS
15
PAGE
413 — Tinea Tonsurans; Ring-worm of the Scalp, 414 — Tinea Circinata,
416— Miliaria; Prickly Heat, 416.
Diseases of the Ear 418
Earache, 418 — Acute Otitis, 418 — Deafness, 422 — Chronic Suppurative
Otitis, 422 — Mastoiditis, 423.
Glandular Diseases 424
Acute Adenitis, 424— Persistent Adenitis, 425— Adenoids, 426— Retro-
pharyngeal Adenitis, 429 — Tuberculous Adenitis, 430.
Heredity and Environment 43I
Habits, 432— Masturbation, 433.
Constitutional Disorders 437
Icterus; Obstructive Jaundice, 437 — Obesity, 438 — The Anemias of
Infancv and Childhood, 438 — Rachitis, 441 — Scorbutus; Scurvy, 445 —
Sporadic Cretinism; Infantile Myxedema, 445 — Status Lymphaticus,
449 — Purpura, 449— Hemophilia, 450.
Infectious Fevers 452
Influenza, 452 — Malaria, 454 — Typhoid Fever, 456 — Erysipelas, 461 —
Rheumatism, 463 — Peliosis Rheumatica, 468 — Acute General Peritoni-
tis, 469 — Tuberculous Peritonitis, 469 — DactyHtis, 470 — Tuberculous
Bone Disease, 471 — Glandular Fever, 471 — Cyclic Vomiting, 472.
Temper.^ture in Children 474
Obscure Elevations of Temperature, 477 — Cold Sponging in Fever, 480 —
The Cool Pack, 481— Bathing the Sick, 483.
Vaccination 484
Instructions for the Summer 487
Rules for the Care of Dispensary Infants and Young Children during
the Summer, 489 — Summer Resorts, 491.
Therapeutic Measures 493
Counter-irritants, 493 — Anesthetics, 494 — Colon Flushing, 496 — Alco-
hol, 497 — Heat as a Therapeutic Agent, 498 — Cold as a Therapeutic
Agent, 499 — The Therapeutic Value of Climate, 500 — Promiscuous Use
of Drugs by the Family, 501 — Unpalatable and Nauseating Drugs, 502.
Gymnastic Therapeutics 505
Rules, 505— Posture and Breathing, 508— Breathing, 513— Flat Chest,
516 — Kyphosis, 518 — Scoliosis, 521 — Congenital Ataxias, 526 — Ante-
rior Poliomyelitis, 539 — Constipation, 541 — Flat-foot, 543.
Drugs and Drug Dosage 545
For Internal Use, 545 — For External Use, 558.
Index 563
THE TREATMENT
OF THE
DISEASES OF CHILDREN
GENERAL CONSIDERATIONS
THERAPEUTICS IN CHILDREN
If I were asked what I considered the chief requisite for the
successful practice of pediatrics by a competent physician I would
answer: The education of the mother. It is impossible to do even
fairly good work in diseases of children without proper home co-
operation. The simple giving of a direction is never followed out
as well as when the reason for it is understood.
Much of our beneficial results is due to the therapeutic influences
of remedies outside of the realm of drugs. Thus, diet, fresh air,
cold, heat, massage, electricity, climate — all are important therapeu-
tic agents in the diseases of children. Successful therapy in children
involves an understanding, a knowledge of detail, greater perhaps than
in any other line of medical work. It not infrequently is an absence of
such knowledge on the part of medical men which explains a great
deal of the therapeutic doubt existing at the present time. Thera-
peutic nihilism, as far as pediatrics is concerned, means ignorance and
incompetency. The time when the physician can make a diagnosis,
and cease his interest in the treatment of the case is past. One of
two things will happen in the absence of interest or ability on the
part of the physician. The faith of humanity in curative agents is
remarkable, and when the desired end is not reached by the first
physician, some other physician is called ; and when he fails, the next
resort usually is the charlatan and the proprietary and patent
medicines.
The prosperitv of the irregular schools of various cults and
sciences supposedly healing in character and the consumption by the
people of millions of dollars' worth of useless proprietary and patent
drugs are to be attributed in a large degree to an indift'erent ap-
plication of therapeutic measures on the part of otherwise well
qualified medical men. A few great teachers of medicine have
1 8 GENERAL CONSIDERATIONS
done an incalculable amount of harm by precept and example in
their attitude toward therapeutics. Because they were or are
unable successfully to treat disease they assume that it cannot be
done. Thus therapeutic doubt, using the term therapeutics in the
broad sense, has been in the past boasted of by men considered
clever. Text-books on pediatrics are not without fault in encourag-
ing careless practice, with necessarily an absence of favorable
results, especially when they state that "treatment is along sup-
portive lines." What constitutes "supportive lines" in a given
case? How is the practitioner to know the author's mind? Or,
again, perhaps it is stated that "free stimulation" is necessary.
Stimulation how, when, why, and by what means is what must be
known, in order to achieve satisfactory results. "Treatment ac-
cording to the indications of the case" does not help a puzzled
physician to any great extent. "Treatment along the same lines
as in adults," adds no illumination when a desperately sick child
is the patient, and moreover is faulty teaching, for the reason that
the treatment in such instances should never be the same as in
adults. An infant or young child can never be treated the same
as an adult, either by drugs or other measures, unless we wish
more thoroughly to convince ourselves of the uselessness of thera-
peutic measures. In order to practise therapeutics successfully in
children the methods of the physician must be flexible and adaptable.
Children vary greatly in their physical and mental equipment, much
more than do adults. The practice of pediatrics is necessarily
difficult, for every case has to be studied from its own standpoint.
The physician who invariably treats all his cases alike will never do
the highest class of work with children. The man, for example,
who feeds all his difficult feeding cases after one rule or pattern will
be sure to have some other practitioner get his failures, which will
not be few. A source of disappointment to physicians, particularly
in the treatment of young infants and children, is in the disorders
of nutrition. A tremendous amount of patience is required in
dealing with such cases, and the absence of prompt results is one of
the difficult features he has to contend with in his relations with the
family. There is, further, a distinction to be made as to what con-
stitutes good results. If the infant develops into a strong child,
we may chronicle our results as satisfactory even though a year was
required before the condition of the patient was satisfactory. To
cause a malnutrition baby weighing only eight pounds at six months,
with marked milk incapacity, to show rapid growth by any method
of artificial feeding is unusual, and our results are good if he gains but
little during the first few weeks.
Chronic colitis, tardy malnutrition, or nephritis may require
months and years for correcting and yet furnish satisfactory results.
In therapeutics in infants and children, particularly as regards the
CLOTHING, ETC., FOR THE EXPECTED BABY 19
use of drugs, two points are to be kept in mind — the benefit hoped
for and the possible harm that may result. A great deal of judgment
must be used in the selection of remedies and the means of using
them lest our best intentions result disadvantageously to the patient.
Thus, in bronchitis and in bronchopneumonia the ammonium salts
are often given in combination with heavy syrups such as tolu and
wild cherry, both possessing little or no expectorant value, but they
possess the property of interfering seriously with the patient's diges-
tion. Doubtless alcohol used indiscriminately is, on the whole,
productive of more harm than benefit, largely through disturbing the
digestion. Digitalis, the salicylates, and the potassium and sodium
salts are all to be used with judgment as to method and time of
administration or they will do more harm than good. A point
never to be lost sight of in the treatment of diseases of children
is the desirability of keeping the gastro-enteric tract in the best
possible condition. In children there are other factors also that
bear upon the case that tend toward good or evil. The most careful
diet and the best selected medication are of little value if the patient
is overclad, kept in a superheated room with anxious, oftentimes
nervously exhausted persons in constant attendance, with the dis-
turbance to the patient which such attendance entails. However,
it must be remembered that absence of proper detail and good
judgment with resulting failures is no argument against the value
of therapeutic measures, although it often furnishes the evidence
upon which the argument is based. Much may be accomplished, by
means of prophylaxis, in lowering the mortality in children under
five years of age. In these the educated mother's aid is invaluable.
She will lay aside prejudices and unfavorable family influences when
a physician's direction appeals to her reason. Marasmus, malnu-
trition, and the intestinal diseases of summer, which directly or
indirectly are the cause of thousands of deaths yearly, are to a
large degree preventable if the right step is taken at the right time,
through the earlv appreciation of danger-signals on the part of both
the physician and the mother.
CLOTHING AND ADDITIONAL REQUIREMENTS
FOR THE EXPECTED BABY
The physician should instruct the young woman w^ho for the
first time expects to become a mother as to the necessary clothing
and toilet articles which she will need for her convenience in the
care of the child. A basket in w^hich all the toilet necessities for
the baby may be kept together will be found a great convenience
when the time for their use arrives.
The basket should be provided with a good-sized pin-cushion
and pins;
20 GENERAL CONSIDERATIONS
Puff-box and puff;
Soap-box, containing castile soap;
Infant's hair-brush and fine comb;
Eight ounces of a saturated solution of boric acid for mouth
and eyes;
One-half pound of absorbent cotton;
A package of wooden toothpicks;
A flexible tube of white vaselin ;
A bath thermometer;
One yard of plain sterile gauze;
Plenty of soft old linen ;
Six of the best baby towels;
A white eiderdown blanket one and one-half yards long ;
One pair of small scissors ;
A package of nickel-plated safety-pins (three sizes) ;
Clothing to be provided:
Forty-eight cotton diapers, made from birdseye cotton diaper;
two sizes are necessary:
(a) Three pieces 20 inches wide.
(b) Three pieces 22 inches wide.
One yard of white flannel for belly-bands. Leave the piece as
it is, to be used by the nurse as required. After the sixth week,
knitted bands with shoulder-straps are preferable.
Four second-size silk-and-wool shirts ;
Six pinning blankets made of white flannel with cotton bands ;
Three flannel shirts;
Three eiderdown wrappers;
Three Cashmere sacques ;
Three bath aprons of shaker flannel for the mother or nurse, to
be used to cover the baby after he is taken from the bath ;
Three pads, each one yard square, and three each one-half ^-ard
square. These are necessary for the crib and lap.
Diapers. — Diapers are best made from soft light-weight goods
which absorb readily. Birdseye cotton diapers are satisfactory.
The diaper should be removed when soiled and placed in a covered
pail containing a carbonate of sodium solution, one ounce to two
gallons of water. Before using, whether soiled with urine or feces
they should be boiled and washed with plain castile soap. Several
rinsings will be required before the napkins are dried, so as to remove
the soda and the soap. They should not be dried in the nursery.
The rubber protector used as a cover for the napkin should be used
only during cold weather and when the child is out of doors. After
changing the diaper the mother or nurse must immediately scrub
her hands and nails thoroughly with hot water, soap and brush.
A diaper washer unique in design and satisfactory in its work is
the washer known in the market as Cunnee's sanitary napkin
THE YOUNG MOTHER 21
washer/ This is so constructed that it may be attached to the hot-
water pipe of any bath-room. It does away with the disagreeable
features of diaper washing by hand and lessens the dangers of con-
tamination of food apparatus and food at the hands of the nurse.
THE YOUNG MOTHER
In order to achieve success in pediatrics, the physician requires
the active cooperation of trained helpers. The more capable the
mother and nurse, the greater the success that will crown his labors
when children are his patients. The physician, therefore, should
undertake the instruction of the young mother in the rudiments of
the child's care. In my own experience, the intelligent mother,
regardless of her station of life, has proved a most satisfactory
pupil. Endowed with good common sense, with her powers for
reasoning well developed, and possessing an ability to appreciate
scientific principles, her usefulness as a mother is thus increased
tenfold.
In order to secure her full cooperation and confidence she must be
told not only what to do, but how and why it should be done. In
the matter of infant-feeding, for example, if it is explained to a
mother of fair intelligence that condensed milk and the proprietary
foods, when prepared for use, are weak in fat, weak in proteid, and
contain much less of these nutritive elements than does mother's
milk — the food which the child has a right to demand — she will at
once be convinced that such food is not suitable for her baby. It
will then be comparatively easy to convince her that cow's milk
for the great majority of infants is the only suitable substitute for
mother's milk.
It is my object to have the mother know as much of child life
as she is capable of understanding. She is encouraged to attend
lectures to mothers and mothers' meetings. She is advised to
subscribe for mothers' journals and to buy books and reading-matter
for mothers, for the reason, which is perhaps not entirely unselfish,
that I have had signal success with the infants of well-informed
mothers. The children of such mothers, as the result of a properly
regulated life, have better appetites and less illness; they are stronger
and more vigorous than those indifferently cared for. If disease
attacks them, they make more prompt and satisfactory recoveries;
if an operation is required, intelligent mothers appreciate its necessity.
As children, their offspring are better specimens of the race, and as
adults, they will always have reason to be thankful that their mothers
were educated and efficient in child management.
A mother should know what to do in case of sudden illness and
she should know when to send for the doctor. I teach the mothers
' Manufactured by The International Sanitary Manufacturing Co., Portches-
ter. New York.
2 2 GENERAL CONSIDERATIONS
of my patients never to look lightly upon a sore throat or trust to
their own judgment in dealing with it, with the result that repeatedly
cases of diphtheria have been on the way to recovery when an
ignorant mother would be treating them by home methods with the
children growing rapidly worse. By the ignorant, I do not neces-
sarily mean the poor. Many of my dispensary mothers show sur-
prising intelligence and good judgment when it is most needed.
A mother should be taught never to rely upon her own judgment
if a child complains of persistent pain in the stomach. She is told
that it oftentimes means a great deal more than simple colic. I
have known precious lives to be lost because the mother made a
diagnosis of colic and treated the child for such a condition, when
it had appendicitis. A mother should be instructed to stop milk,
to give a dose of castor oil and a carbohydrate diet with the first
indication of summer diarrhea, and then to send for the physician, no
matter how trivial the indisposition. She is told that, in the intes-
tinal diseases of summer, the child is poisoned by a process of bacterial
infection in the intestinal contents and that milk furnishes the best
food for the bacteria that cause the trouble. She is told that the
child who is badly fed and who has repeated attacks of indigestion
and diarrhea during the winter and spring will be much more suscep-
tible during the summer to serious intestinal involvement ; and
that proper feeding and the immediate correction of digestive errors
are of paramount importance at all seasons of the year. She is told
how to dress her child in summer. She is taught the necessity of
fresh air at night and the value of outdoor life at all seasons of the
year; that a so-called "cold" is usually an infection of the respiratory
mucous membrane due to dusty ill-ventilated rooms or dusty streets
and not to the fact that a window was left open for a few moments ;
that a child cries from other causes than hunger ; that fever, whatever
its cause, requires that the child's food be weakened at least one-half
in the bottle-fed, and that an ounce or two of water be given before
nursing in the breast-fed; that drug-giving to children is a habit
which is to be condemned, the child in health requiring little or
nothing in that line.
With an educated mother not only are our "results much more
satisfactory, but the annoying outside influence of officious relatives
and neighbors is thus effectually neutralized.
THE NURSERY MAID
In certain stations and conditions of society, the young child is
cared for by its mother with the assistance of the immediate members
of the family. In thousands of homes, however, a helper is employed
to take charge of the child or assist in its care. The selection of a
nursery maid is a matter of much importance. Schools for training
THE NURSING- BOTTLK AND NIPPLE
2.3
nursery maids exist in New York city, Boston, Albany, Newark
(New Jersey), and doubtless in some other cities; but, although
such trained help is greatly to be desired, the supply is very limited.
Some of my best children's attendants have iDeen women who,
although they have not passed the meridian of life, still have reached
the seasoned age when the attractive qualities of policemen and
grocery boys have faded into a dim recollection ! Any industrious,
sensible young woman of quiet tastes who is fond of children, can be
trained in a few weeks into a most useful helper. The association
of the nursery maid and child is a close one, and it is the physician's
duty to know that the applicant is physically fit for the position.
During the past year the writer has known of three nursery
maids who developed pulmonary tuberculosis while in service.
Not only should the applicant's lungs be examined, but also the
mouth, nose, and throat. Carious teeth, and diseased conditions
of the throat and nose, should receive careful attention before the
maid is allowed to assume the position. It is also important that
something of the applicant's previous life should be known.
One of the most important things to know about an applicant
in a large city, and one most difficult for the physician to discover,
is the matter of leukorrhea or vaginal discharge.^ This, however,
can usually be discovered by the tactful young mother. Not only
should the ideal nursery maid be physically fit, she must be mentally
fit as well. For proper mental and physical development, children
must be entertained and pleasantly employed. An ill-natured,
impatient nurse should be forced to seek other employment. It
should not be a task for a child's attendant to play wdth him. A
woman should not be condemned, however, because she fails with
any given child. With a child differently situated, with a different
temperament, the results may be perfectly satisfactory. I have
known not a few such instances.
THE NURSING-BOTTLE AND NIPPLE
There are two requirements that a nursing-bottle must fulfil:
It must have a capacity sufficient for one full feeding and it must be
so constructed as to be readily cleansed. The oval bottle (Fig. i)
with rounded edges answers best. These may be obtained in sizes
of from three to nine ounces. As many bottles are needed as there
are feedings in twenty-four hours. The bottle should be boiled
once a day, scrubbed with a stiff brush with hot borax water, and
remain in the borax water until needed. Two teaspoonfuls of borax
to a pint of water is the strength usually used. Before using, bottles
should be rinsed in plain boiled water. The straight, black nipple
' A very severe gonorrhea was recently contracted by one of my patients
from a nursery maid.
24
GENERAL CONSIDERATIONS
(Fig. i) is also preferred, for the reason that it can be turned inside
out and easily cleansed. A nipple which cannot be turned should
never be used. After using, a nipple should be turned and scrubbed
with a stiff brush and borax water — a tablespoonful of borax to a
pint of water. When not in use, the nipple should be kept in borax
water. Before placing it on the bottle, it should be rinsed in boiled
water. The nipple should be boiled once a day. The blind nipples —
those without holes — are the best. Holes of the
A required size may be made with a red-hot cam-
bric needle.
THE NURSERY
The nursery should be the largest and best
ventilated room in the house. In a city home it
is well to have it on the third or fourth floor with
a southern exposure. In apartments, quiet and
the possibility of free ventilation and sunlight
must be considered in selecting the room. For
the sake of quiet, the nursery should not com-
municate with the sleeping-rooms of older chil-
dren.
In placing children in sleeping-rooms or in a
nursery or in estimating the capacity of hospital
wards for children, it is to be remembered that at
least one thousand cubic feet of air-space should
be allowed to each child.
The floor of the nursery should not be car-
peted. A hard-w^ood floor is best. If this is not
possible, covering the floor with oil-cloth or lino-
leum is always possible. This can be cleaned with
a damp cloth every day. A broom should never
be used in a nursery. Paint or hard finish on the
walls is preferable to paper. There should be at
least two windows and an open fireplace. If pos-
sible, the bath-room should be connected with the
nursery, to be used not only for bathing the child
but as a "changing room." The child's napkins
should not be changed in its living-room if it can
be avoided. It is needless to say that napkins should never be dried
in the nursery.
Steam heat as ordinarily used today is the least desirable means
of heating, on account of its uncertainty. In many New York
apartments of the better class, the fires are banked at lo p. m. ; the
temperature when the child retires is from 70° to 80° F. or more;
by five or six o'clock in the morning a fall to from 50° to 60° F. has
taken place. Such a change in the temperature, with the tendency
Fig. 1.— Nursing-b
TLE AND Nipple,
BASKETS FOR EARLY EXERCISE 25
of children to kick off the bed-clothes, explains many cases of ton-
sillitis and bronchitis. The temperature of the nursery should be
kept as even as possible. When for any reason this cannot be con-
trolled, it is best to have two means of heating, so that when one fails
the other may be used. The open-grate fire or a small wood-stove
is best. Gas ought never to be employed as a means of heating a
child's sleeping-room, on account of the rapid exhaustion of the
oxygen which results from its use.
The furniture of the nursery should be of the plainest. Hard-
wood chairs and tables with enamel or brass cribs or bedsteads
should be used. There should be no article of furniture or fur-
nishings in a nursery, that cannot be washed. There should be in
the bath-room or in some room adjoining, a pail containing some
disinfectant solution, such as carbolic acid, i : 100, in which the
napkins are placed as soon as soiled.
There should be two shades at each window, a light and a dark
shade, so that it will be possible to darken the room during the
sleeping time, as well as to exclude the early morning light, which
is the usual cause of too early waking. Babies should be taught
to sleep until at least six o'clock in the morning. This is far better
for the child and also for the mother if she occupies the same room.
The unnecessary habit of an early waking at four or five o'clock will
in most instances readily be broken by keeping the room dark.
The nursery should have suitable means for ventilation. For
this purpose, aside from the fire-place, I have found the window-
board (page 43) of no little service. It can be made of any width.
Ordinarily, I have it made about four inches wide. It is sawed
so as to fit tightly under the lower sash. This leaves an open space
corresponding to the width of the board between the upper and
lower sash, and allows the entrance of a current of air which is directed
upward. There should be a thermometer in every child's living-
room or nursery. It should register from 70° to 72° F. by day and
from 66° to 70° F. by night. The nursery should be given an hour's
airing twice a day. The child should sleep alone in its crib. It
should not sleep with an adult or an older child. The old-fashioned
cradle in which generations have been rocked may be an interesting
heirloom, but under no circumstances should it be removed from
its place in the garret.
BASKETS FOR EARLY EXERCISES
It is a mistake made in many families to have the baby in the
arms a greater part of his waking hours. This practice should be
discouraged by physicians, for when the child is held, there is always
a tendency to make him sit upright on the arms or knee without
proper support. During the early months of life the vertebrae and
vertebral ligaments are not sufficiently developed to support the
26 GENERAL CONSIDERATIONS
heavy head and trunk. If this thoughtlessness on the part of
parents with its attendant dangers were explained, there would be
fewer cases of displaced scapulae and spinal curvature to be treated
later on. Many of the cases of spinal curvature which we see are
the direct outcome of such early abuse of the spinal column. Still,
it is not desirable that the child should constantly occupy its crib.
A large clothes-basket in which a thick blanket and pillow have been
placed furnishes a safe playground for a small baby. For the first
few months he will lie on his back and amuse himself in his own
peculiar way. After the sixth month, when he may be allowed to
sit up for a short time each day, a pillow should be placed behind
his back for support. The basket furnishes plenty of room for toys
and other means of entertainment. When the child begins to stand
and attempts to walk, the basket period is at an end and the exercise
pen (page 37) should be brought into use.
THE CARE OF THE STUMP OF THE UMBILICAL CORD
The space devoted to the care of the umbilical cord might seem
out of place in a work of this nature. The excuse for it is the fre-
quent appearance in private practice and in out-patient clinics of
infants with umbilical polypi, granulomata, suppurating umbilical
stumps, or an eczema involving a considerable area about a moist,
actively secreting umbilicus. The management of granuloma,
polyp, and localized eczema about the umbilicus has been referred
to elsewhere. In order to secure a rapid and complete cicatrization
after the cord falls, it is always desirable to keep the parts dry. I
have used with gratifying success a powder composed as follows :
I^. Pulveris acidi salicylic grs. x
Pulveris acidi borici grs. xxv
Pulveris amyli
Pulveris zinci oxidi aa 5 ss
Over this powder, which is used freely in the open wound, is
placed a pad of gauze to hold it in position. The dressing should
be changed and fresh powder applied every time the child is fed.
For the small unhealthy granulations which will often be present,
cauterizing with a 50 percent nitrate of silver solution may be
necessary once or twice, after which the powder is used until the
secretion has entirely ceased and cicatrization is complete.
CRYING
It is wxll for the young infant to cry a little every day. Muscular
movements involving a greater part of the body accompany the act
of crying and furnish exercise. Peristalsis is increased, as is often
evidenced by a movement of the bowels occurring at the time,
particularly when there is diarrhea. In crying, deep breathing is
necessary, the lungs are expanded, and the blood oxygenated. The
well baby cries when frightened, or uncomfortable from hunger,
soiled napkins, or inflamed buttocks. He cries from pain, from
heat, from cold, from unsuitable clothing, and during difficult
evacuation of the bowels. He also cries when displeased or angry.
Authors are prone to refer to the diagnostic value of an infant's
cry. It is my belief that characteristic cries are not to be depended
upon sufficiently to give them a differential diagnostic dignity.
Children slightly but painfully ill may cry incessantly for an hour
or two. Thus, with intestinal colic, where the cry is loud and con-
tinuous until the child is relieved or until he falls asleep from exhaus-
tion. Earache is not an infrequent cause. The habitual criers, the
restless and vigorous, crying, whining infants, are uncomfortable.
With ver}^ few exceptions the trouble will be found in the intestinal
tract. The well-trained, normal child, whose nourishment is suitable,
is seldom troublesome. When well, all babies are naturally good-
natured and happy in their own way. Badly managed, spoiled
infants often cry vigorously when deft alone. When attention is
given them, when they are taken up and talked to, the crying ceases.
This readily tells us that pain or discomfort was not an element in
causing the cry. In these infants, discipline, not medication, is
needed. The management of the habitual crier involves the relief
of the condition which causes the discomfort, or the most rigid
discipline.
SLEEP
The infant that sleeps well is almost always a normal, well-fed
baby. Irritability and sleeplessness are associated with indigestion
more frequently than with any other disorder. During the first
few days of life, the sleep, in normal conditions, is almost unbroken,
except when the infant is fed. During the first month the infant
sleeps about twenty-two hours out of every twenty-four. During
the second and third months, from tw^enty to twenty-two hours.
At the sixth month the child should sleep from 6 p. m. to 6 a. m.
without interruption other than for feeding or nursing, which need
cause very little disturbance. At this age there should be a two-hour
nap during the morning and a two-hour nap in the afternoon, although
it is not well to have the baby sleep after three o'clock in the after-
noon. The twelve-hour night rest should be continued until the
child is six years of age. The day naps will gradually be shortened
by the child. At one year of age, one hour in the morning and two
hours in the afternoon suffice. From the eighteenth month to the
second year, the morning nap is given up. Afternoon rest for at
least one and one-half hours should be continued until the child
is six years of age, and longer if he is inclined to be deHcate. Regular
sleep is largely a matter of habit, and if the infant is started right
with suitable feedings given at definite times, followed bv the proper
period of sleep, but little trouble will be experienced with sleepless-
28 GENERAL CONSIDERATIONS
ness. When sleep is disturbed and broken, it means bad habits,
unsuitable food, minor forms of indigestion, or positive illness of
some kind. Sleep is important for purposes of growth, not only in
early infancy but throughout childhood. Not a few infants form
habits of sleeping in the daytime and being wakeful at night. This
is best remedied by keeping the baby awake, when he should be, during
the day, by entertainment and by keeping him in a well-lighted
room. I am sure that the satisfactory results which I have had the
good fortune to achieve in the treatment of secondary malnutrition
and anemia have been due in part to my insistence that the child
sleep in a quiet, darkened room for two hours after the noonday meal.
The energy expended in twelve hours by an active child is incal-
culable, and when a portion of this energy is reserved and the body
fortified by rest and sleep during the middle of the day, it means a
greatly diminished daily expenditure of strength units.
KISSING
Such a topic may be considered out of place in a work of this
nature, but in taking up the child's management in all its details,
it is my belief that a few remarks on this subject are perfectly in
order. Every detail of the child's daily life should be under the
oversight of the ph^^sician, and if he is to do his full duty, he must
give a certain amount of voluntary, unsought advice. A custom
concerning which he will not be consulted is the matter of that
most unhygienic practice of kissing.
A child should never be kissed on the mouth, and this is a standing
order wdth all my patients. I have known, in my own private
practice, of instances where tuberculosis, diphtheria, and syphilis
have been communicated from the diseased adult to the innocent
child by this disgusting practice. Neither should the child's hands
or fingers be kissed, as the hands and fingers of the majority of
babies are in their mouths many times an hour. If the baby is
the first one that has graced the household, and must be kissed,
this can be accomplished with the least damage, if the kiss is im-
planted on the head or forehead. The parents must make the rule,
and they must set the example by adhering to it themselves. Among
my patients, a nurse who is known to have kissed the child is pun-
ished by dismissal. Because an adult is apparently well, is no excuse
for this indulgence. Healthy adults frequently have in their mouths
the germs of tuberculosis, of diphtheria, and of other diseases, and
never suffer from their presence because they are strong adults
w^ith vigorous mucous membranes which do not furnish as favorable
a soil for the growth and development of pathogenic bacteria as do
the more delicate mucous membranes of the young. It is criminal,
therefore, to subject the child to such dangers. Scarlet fever,
measles, and whooping-cough are all most readily transmitted at
BATHS
29
the beginning of an attack through the close contact required by
a kiss.
Kissing should not be allowed among children. Little girls are
very prone to follow the customs of their mothers, whether good or bad ;
hence, the necessity of advice in this direction which will be partic-
ularly impressed upon the physician if he will observx' the inter-
change of bacteria which takes place on the sailing
or arrival of any of our large ocean steamers !
BATHS
The newly born child should be given daily
a basin-bath with lukewarm, boiled water and
castile soap until the cord falls and the navel
heals. When this has taken place the tub-bath
may be given. The temperature of the bath for
the very young infant should not be below 95° F.,
nor above 100° F. Very 3-oung children should
not be kept in the water more than three min-
utes. After the third or fourth month a temper-
ature of 90° or 95° F. is best, the child being kept
in the water about five minutes. At this age I
prefer to have the tub-bath given at night, just
before the child is put to bed. A basin-bath may
be given in the morning. When the child is a
year old and fairly vigorous, the temperature of
the water at the beginning of the bath should be
90° F. This should gradually be reduced to 80° F.
by the addition of cold water, the child being
vigorously rubbed with the hand while in the
water. The temperature of the room should be
from 76° F. to 80° F. during the bath, and win-
dows and doors should be closed, ^^'hen removed
from the tub the baby should be dried quickly and
thoroughly, and the folds of the skin should be
well powdered. A sponge should never be used
in any portion of the bathing process. It should
never be included in the nursery outfit. It is
never clean after it has once been used. vSome
children have a dread of the bath, and cry fran-
tically when placed in the water. This is due to
fear, and may usuallv be overcome by placing a sheet over the tub
and lowering the child on it into the water.
The Cold Douche. — For " runabouts " from two to three years old
it may not be wise to use water below 70° F., but many patients
over three years have the water applied in the form of a cold douche
after the cleansing bath, during the entire twelve months at the
m
i'if%
Fig. 2.— Bath Ther-
mometer.
30 GENERAL CONSIDERATIONS
temperature at which it runs from the faucet. In winter, in New
York houses, this ranges from 50° to 60° F.
In giving the cool douche the child should stand in warm water
covering the ankles. The douche may be used in the form of a
spray or shower or the water may be applied by means of a sponge
moistened with it at the desired temperature. The head, if the
showier or spray is used, should be suitably protected by an oil-
skin or rubber bathing cap.
After the cold douche there should be a vigorous friction of the
skin with a rough towel. If there is not a quick reaction, if the skin
does not become warm and glowing, warmer water should be used.
So also with blueness of the extremities and "goose flesh," use
water less cold, but do not discontinue the douche.
In the great majority of homes the bathing of the children can
be carried on with greater convenience immediately before their
bedtime. The child should receive the warm bath and the cool
douche, and then, in night-clothes, a warm wrapper, and suitable
foot covering, he should eat his supper. How'ever, if this time is not
convenient, he may be given the evening meal at 5.30 or 6.30, followed
in one hour bv the bath and bed.
Tub-baths for Fever. — Place the child in water at a tempera-
ture of 95° F. and reduce to 75° F. or 80° F. by the addition of ice
or cold water. The duration of the bath should not be more than
ten minutes, constant friction being maintained during the entire
process.
Basin Bathing for Fever. — Add eight ounces of alcohol to a
quart of water at a temperature of 70° F. The child is stripped and
covered with a flannel blanket, and the entire body sponged with
this solution for ten or fifteen minutes.
Either the tub-bath or the basin-bath may be used by the mother
in case of sudden high fever — 104° to 105° F. — before the physician
arrives. She should be so instructed.
Bathing for Comfort in Hot Weather. — The basin-bath and
tub-bath may also be used as a means of relief during very hot
weather. One or two basin-baths a day, with a tub-bath at bedtime
during this trying season, will give the child much relief, and help
him to pass safely through it. The very young feel the extreme
heat most acutely, and endure it with difficulty. I know of nothing
else that will give a restless, uncomfortable, heat -tormented child
such a refreshing sleep as w^ill a cool basin-bath.
Mustard Bath. — A mustard bath is prepared by adding a
heaping tablespoonful of mustard to six gallons of warm water.
One of the uses of the mustard bath is in the treatment of convulsions ;
it will be found useful also for nervous children who sleep badly.
Two or three minutes in the mustard water, followed by a quick
rubbing immediately before going to bed, is oftentimes all that will
be required to induce refreshing sleep.
WEIGHT 3 1
Brine Bath. — A brine bath — an even tablespoonful of salt to
one gallon of water — is of great service with very delicate, poorly
nourished children. Its action is that of a tonic. If the child is
thoroughly soaped and washed with plain water, and then immersed
in the brine bath, no further tubbing is necessary. The child should
be kept in the bath for five or ten minutes, constant friction being
continued during the entire time.
Soda Bath. — The soda bath is of some service in cases of prickly
heat from which many children suffer during the summer. A
tablespoonful of bicarbonate of soda should be added to each half
gallon of water used. The temperature of the water should be that
to which the child is accustomed. From two to four minutes in the
water suffices. There should be little or no friction of the skin.
The child should be dried with soft towels.
Bran Bath.— The bran bath also is of service in prickly heat.
One cup of bran is mixed with the water in the bath-tub and the
same method employed as for the soda bath.
Starch Bath. — The starch bath also is useful in prickly heat.
One-half cupful of powdered laundry starch is mixed with the water
in the bath-tub, and the same method employed as for the soda bath.
Hot Bath. — Place the child for from three to five minutes in
water which has been raised to a temperature of 105° or 110° F.
Constant friction of the extremities is maintained while in the water.
WEIGHT
The average weight of the full-term newly born infant varies
from six to nine pounds. Some are born at term weighing less than
six pounds and a few weighing over nine pounds, but in the great
majority the birth-weight will be found between these figures. Holt
found from a study of the records of three large maternity institu-
tions in New York city as follows :
The average weight of 568 females was 7.16 pounds.
The average weight of 590 males was 7.55 pounds.
Every family which can afford it should have a scale (page 33)
for weighing the baby, for only by regular weighing during infancy
and childhood can we gain an accurate knowledge of the growth of
the child. During the first five days of life there is usually a loss in
weight of from four to six ounces. After this initial loss, which may
be expected but which does not always occur, a weekly gain in weight
is to be looked for, the child regaining the birth-weight on the eighth
or tenth day. At first it is advisable to weigh twice a week, or
even daily, if the child is not progressing satisfactorily. After the
second month, when he is making satisfactory progress, a weekh-
weighing will answer, and this should be continued until the child
is one year of age. During the second year, bi-monthly weighings
are sufficient. Girls of the same age, after the first year, will average
32 GENERAL CONSIDERATIONS
from one-half to one pound lighter than boys. During the third
year, monthly weighings will be sufficient to enable one to keep
in touch with the child's condition. During the first six months
of life a weekly gain of from four to eight ounces has been made
by the well children under my care. When a child does not make
at least an average gain of four ounces weekly, I do not put him in
the "doing well" class, but look into his care and nutrition to learn
what is wrong. Children vary in their growing capacity. Some
will increase in weight rapidly, gaining three ounces a day, which I
have seen in some cases, while others will make a slower gain and yet
be perfectly well. Through the care of many children, I have come
to regard four ounces as the minimum weekly gain for a well child.
In a well infant the birth-weight should be doubled by the fifth or
the sixth month, and in one year his weight should be a little over
two and one-half times that at birth. During the second year a gain
of from five and one-half to seven pounds will usually result under
proper conditions. During the third year from five to six pounds
will be added. At the fifth year the weight should be in the neighbor-
hood of forty-one pounds. It is not to be inferred that these are
arbitrary figures or that perfectly well children may not be under
or above the figures given at the ages mentioned. They are, however,
to be regarded as the averages for the different ages.
A weight chart with its colored "normal" line will not be found
in this book and physicians are advised against its use. Time and
again I have seen well infants, though slow in growth, made ill by
overfeeding, in the vain attempts of an ambitious mother or nurse
to keep her infant up to the " normal " line. It may be said that the
weekly weighing might have similar effect; not so. Here there is
nothing for comparison — no normal red line staring the mother in
the face.
The weighing alone is not sufficient to tell us absolutely as to
the development of children. I have seen condensed-milk babies who
showed a most satisfactory weight curv^e, 3^et who, on examination,
were bv no means up to the requirements for their age as regards
their bone and muscle development. A nursing or bottle baby
should be examined once a month in order to determine if the prog-
ress is along the desired lines as shown by the condition of the
teeth, the fontanel, the long bones, and the muscles.
The following table from Holt's " Diseases of Infancy and Child-
hood" gives the weight and height of children from birth to the
sixteenth year. The weights under five years are in children without
clothing. After the fifth year the weight of the clothing is to be
deducted. The average weight of house-clothing, according to
Holt, who quotes Bowditch, is at the fifth year 2.8 pounds for both
sexes; at the seventh year, 3.5 pounds for both sexes; at the tenth
year, 5.7 pounds for boys and 4.5 pounds for girls; at the thirteenth
WEIGHT 33
year, 7.4 pounds for boys and 5.6 pounds for girls; at the sixteenth
year, 9.7 pounds for boys and 8.1 for girls. These weights must
be deducted from the gross weights in order to obtain the net weights
of the children. The season of the year, of course, would make some
difference as to the weight of the clothing, although this point is
not mentioned by the observers.
Age. Sex. Weight. Height.
Pounds. Inches.
Rirth ^^°y" ^-^^ 20.6
^*"^ \ Girls 7.16 20.5
,, /Boys 16.0 25.4
6 "^°"^^^^ 1 Girls 15.5 25.0
,, [Boys 20.5 29.0
12 months | ^j^ 19 8 28.7
,, (Boys 22.8 30.0
18 months | ^j/^^ 22.0 29.7
/Boys 26.5 32.5
2 years ( ^irls 25.5 32.5
/Boys 31.2 35.0
^ y^""'^ \ Girls 30.0 35.0
/Boys 35.0 38.0
4 years |Qi4 34 0 38.0
/Boys 41.2 41.7
5 years (Qij-ls 39.8 41.4
/Boys 45.1 44.1
6 years [q;/^^ 43.8 43.6
/Boys 49.5 46.2
7 years | Qirls 48.0 45.9
/Boys 54.5 48.2
8 years { Qi4 52.9 48.0
/Boys 60.0 50.1
9 years [ Qi/is 57.5 49.6
/Boys 66.6 52.2
10 years ( gMs 64.1 51.8
/Boys 72.4 54.0
11 years ( Qi^ls 70.3 53.8
,^ /Boys 79.8 55.8
12 years | qj^ 81.4 57.1
/Boys 88.3 58.2
1^ years | Girls 91.2 58.7
/Boys 99.3 61.0
1"^ years ( Qi^ IOO.3 60.3
/Boys 110.8 63.0
15 years (Gi4 108.4 61.4
/Boys 123.7 65.6
16 years | ^irls 113.0 61.7
Scales. — A scale for weighing the baby is a very necessary
adjunct to the nursery furnishings. There are several varieties of
scales on the market known as "baby scales." Their usual construc-
tion is that of a basket for holding the baby, the basket being supported
by a steel rod which rests upon a spring. A needle indicates on a
dial the weight of the child. This variety of scale is very unsatis-
factory: it gets out of order easily, it is expensive, and with a vigorous,
kicking child, the rapid oscillation of the needle makes an accurate
reading of the weight a difficult if not an impossible matter. Further,
the weight capacity of these scales is but twenty pounds. AA'hen
34
GENERAL CONSIDERATIONS
the child's weight reaches this figure, it necessitates the purchase
of another scale. The scoop and platform scale used by grocers
(Fig. 3) answer the purpose far better than any other. They do not
easily get out of order, they weigh correctly from one-half ounce to two
hundred and eighty pounds, and being very simple in construction
they can readily be understood. The infant rests on his back in the
Fig. 3.— Scoop and Platform Scale.
scoop during the weighing process ; older children stand on the plat-
form. These scales are inexpensive, costing but $3.75.^
HEIGHT
The length or height of children at the various ages is for con-
venience included in the above table. From the standpoint of
health or development, this is of no great significance. The length
at birth usually varies from 19^ to 21 inches. Children suffering
from tardy malnutrition, particularly if syphilitic, may be under-
sized. Not a few of the non-specific malnutrition and anemic children
are tall and thin. It is often a matter of no little distress to parents,
that their children are undersized. Short mothers and fathers
cannot expect very tall children. They will probably be larger than
the parents if they get the right care, but they cannot be expected
to grow as much as some of their playmates whose fathers and
mothers are tall. The height bears much less relation to the con-
dition of the child than does the weight.
^The scoop and platform scale may be obtained at the Metropolitan Hard-
ware Co.'s, Church and Vesey Streets, New York.
THE TEETH
35
THE TEETH
Twenty teeth comprise the first set. In the well child the first
tooth usually appears between the sixth and the eighth months;
the first teeth may, however, in perfectly normal cases, come earlier
or much later. I have known well, vigorous children who did not
get a tooth until the thirteenth month. The first teeth are usually
the two lower central incisors. The four upper incisors and the
two lower lateral incisors appear normally between the eighth and
the tenth months. The first four molars appear between the twelfth
and the fifteenth months. The four canines between the eighteenth
and the twenty-fourth months, the four posterior molars, which
complete the first set, between the twenty-fourth and the thirtieth
months. This regularity in the appearance of the teeth is by no
means constant, even in well children. I have in several instances
seen the upper lateral incisors appear first. In delayed dentition
the teeth are very apt to appear irregularly.
Care of the Teeth. — As soon as the teeth appear they require
attention. Until the second year is reached the mouth should be
washed out at least twice a day with a solution of boric acid— one
ounce to a pint of water. This can best be done by means of absor-
bent cotton wound around the tip of a clean index-finger and after-
ward dipped into the solution, when it should be applied with
gentle friction to the gums and teeth. When a child is two years
old, it is well to begin the use of a soft tooth-brush and a simple
tooth-powder composed of the following ingredients :
I^. Precipitated chalk 5j
Bicarbonate of soda 5 j
Oil of wintergreen q. s.
The child should also be instructed as to the proper use of a
quill toothpick. The teeth of every child over two years of age
should be examined by a dentist every six months. If cavities are
discovered in the first teeth they should be filled with a soft filling.
The milk teeth are lost between the sixth and the eighth years.
They should not decay, but fall out or be forced out by the second set.
The Permanent Teeth. — The permanent set comprises thirty-
two teeth. The second dentition begins about the sixth year, and
is usually completed about the twentieth year, although it may be
delayed several years. The permanent teeth appear in somewhat
the following order :
First molars sixth year.
Central incisors sixth to seventh year.
Lateral incisors seventh to eighth year.
First bicuspids ninth to tenth year.
Second bicuspids ninth to tenth year.
Canines eleventh to twelfth year.
Second molars thirteenth to fifteenth year.
Third molars after the eighteenth year.
36 GENERAL CONSIDERATIONS
Dentition. — It is claimed that the eruption of the teeth is a
physiologic process and as such is not productive of harm. In
normal well babies this is generally the case. There may be a
slight fever and restlessness with loss of appetite, associated with the
eruption of a tooth, but the disorder is usually very temporary in
character. With delicate children, particularly in those who teethe
late, as in the rachitic when several teeth are cut at one time, not
a little inconvenience may be caused by dentition. Even these
patients, however, rarely have grave digestive disorders. In a large
experience with teething infants, I have known but one in whom
convulsions were apparently directly dependent upon dentition.
The patient was a rachitic institution child who cut his first tooth at
the ninth month, and with each of the three succeeding teeth, which
were cut during the next three months, there were convulsions
without any other signs of illness.
Temporary digestive disorders are of ver}^ frequent occurrence
in this tvpe of child, during an active dentition. The child may
be restless and irritable and perhaps there is fever of a degree or
two. His digestive capacity is lessened, but the usual diet is never-
theless continued. Fermentative diarrhea results, which may be,
and often is, the starting-point of grave intestinal disease. When
it is apparent that the child's generally good-natured daily habit of
life is being unfavorably influenced by dentition, the food should
temporarily be reduced, particularly if the weather is hot..
Breast babies may be given water before each nursing so as to
reduce the capacity for milk. In the bottle-fed two or three ounces
of the food mixture may be removed from each bottle, replacing
the amount with boiled water.
That cough, respiratory and skin diseases are immediate results
of dentition is without foundation. During active dentition when
the gums are distended and swollen from pressure, relief will often
be furnished promptly by rubbing through the prominent points
of the tooth with a clean towel over the index-finger. Lancing
alone may be performed, but unless the tooth is well advanced it
is quite possible that the gums will reunite over the tooth, forming a
cicatrix which will make the eruption more difficult than before.
If a week or ten days' discomfort can be obviated by assisting a
tooth through the gum, I fail to see any contraindication to such a
procedure.
DAYS TO GO OUT OF DOORS; INDOOR AIRING
Phvsicians are frequently consulted as to the age when, and the
conditions under which, it is permissible to take the baby out of
doors. To answer this, the place in which the child lives, the season
of the year, and the age and condition of the patient must be taken
into consideration.
THE EXERCISE PEN ^7
A child, regardless of its age, should never be taken out in inclem-
ent weather. If under one year, he should not go out if the tempera-
ture IS below 20° F. During the midday heat of summer the baby
IS better off m the largest and coolest room in the house, or on a
shady veranda. On very windy days the young infant should not
go out, nor when the snow is melting in large quantities, but, although
unable to go out on account of unfavorable conditions of the weather
there should be no lack of fresh air, and in such conditions children
should be given an indoor airing. For this purpose the child is
dressed as for the daily outing. All the windows of the nursery or
some other large room are opened, on one side of the room onlv
The doors should be closed, so that currents of air are avoided The
child IS placed in his carriage, suitably covered, and wheeled about
the room for an hour or two. This, if done twice daily, answers
almost as well as the actual outing.
This method will be found very useful in "winter babies"—
those born during the late fall or winter months. The indoor airing
may be given for a week or more, before he is taken out. By this
means the child is gradually accustomed to a change of tempera-
ture from that of the average living-room to that out of doors and
will not be harmed when he is finallv taken out. After an illness
also, it will afford an earlier means of returning to the daily outing
This method of giving a child fresh air will be found useful with very
delicate children also, who, by reason of their condition, may be
unable to go out during the winter months, for several weeks at a
time. There are, however, but few days during the winter that are
too cold or too stormy for the indoor airing.
THE EXERCISE PEN
In another chapter, in speaking of "colds" and how children are
exposed to the influences which might bring about what is known
as a "cold," the custom of allowing a child to sit on the floor and
play, at all seasons of the year, is referred to as a most frequent means
of exposure. There is always a current of air near the floor, as one
readily discovers by resting his hand on the floor, on a cold winter
day; further, the floor of the average house is naturally the most
unclean part of the dwelling. Here dust gathers and dirt from the
street collects as it is brought in on the feet of older members of the
family. On this necessarily unclean floor, the young child is per-
mitted to spend a considerable portion of his waking hours. It can
readily be seen that countless numbers of bacteria may be trans-
ferred through the medium of the hands from the floor to the child's
mouth. Rugs and pillows, which are sometimes used, while cleaner
than the floor, are of little assistance in preventing drafts.
Exercise is very necessary for the child's proper growth and
development. He must have an opportunity and place in which to
38
GENERAL CONSIDERATIONS
creep, walk, and run. In order that he may have these advantages
and not be subjected to unfavorable influences, I have found the
exercise pen (Fig. 4) of the greatest service. After being bathed,
dressed, and fed, the child is placed in the pen, on a rug or quilt.
Toys are given him and the door is closed. He cannot come in con-
tact with the stove, he cannot roll downstairs, and he is in no danger
from the rough play of older children. He is given an opportunity
for active exercise without a possible chance of injury.
The pen can be made of any size, but the usual size is four feet
square. It can be made of any hght-weight wood, pine generally
being used. The legs of the pen should be at least twelve inches
Fig. 4.— The Exercise Pen.
long, bringing it well off the floor. The pen is so constructed that
it may readilv be taken apart and put together again, iron tenon
hooks and iron mortices being used to hold the parts together. The
floor may be made of any thin material. One-half inch pine boards
nailed together, or papier-mache supported by narrow strips of
board, may be used. The floor is supported by strips of board about
one-half by two inches, which are fastened to the inner side of the
end-pieces. The pen is best placed in the corner of the nursery or
the living-room. Its size may be determined entirely by the size of
the room. During warm weather in the country, it may often be
used out of doors.
WRITTEN DIRIiCTIONS • 39
THE FIRST EXAMINATION OF A PATIENT
Upon being called for the first time to see a patient, it is my
custom in every case to take a history. On page 40 is a copy of
one page of the history record which I use.
When the history is completed the leaves are placed in a Moore's
loose-leaf binder.
The patient's family history is carefully taken. The habit of
obtaining a complete and accurate record as regards family peculiari-
ties in relation to disease is often of much service, subsequently, if
not at the time. Upon systematic questioning only will necessary
facts be brought out relating to tuberculosis, rheumatism, syphilis,
etc. The child's personal history includes the birth- weight, the
rate of growth, the nature of previous illnesses, present weight, the
condition of the skin, eyes, nose, heart, lungs, tongue, bowels, and
the temperature. All these points are noted and recorded. It is
only by such an examination, requiring much time and patience,
that we are able to become thoroughly acquainted with the case in
hand.
The child must be stripped for the examination when the condi-
tions found are entered in the proper spaces in the history chart.
After the family history has been taken and the general physical
examination completed, we are in a position to devote ourselves to
the present condition of the patient. After one has practised for a
time, thoroughly examining every new case, he is not only impressed
with its value as bearing upon the management of the condition in
question, but is also impressed with the unexpected pathologic
findings in other organs, particularly the heart, throat, and lungs.
The habit of limiting the examination to feeling the pulse, which
the doctor usually does not feel on account of the struggling child,
and the examination of the tongue, which is usually alike unsuccessful,
merits the severest condemnation.
WRITTEN DIRECTIONS
If possible, directions for the care of sick children should be
given outside the sick-room, so that the physician may have the un-
divided attention of the mother or nurse. These directions should
first be given orally and thoroughly explained, and then written
out in detail. With the child crying, and two or three onlookers
talking, the mother or nurse becomes confused and is almost sure
to misunderstand or forget important directions.
If there is not a trained nurse in charge the doctor should show
the mother or nursery maid how to perform the various offices for
the child. She can in a few moments be taught how to read the
clinical thermometer, how to give a sponge-bath and an enema, and
how to do many other things which the changed condition of the
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TRKATMICNT OF THE INDIVIDUAL 4 1
child requires. The use of a croup kettle, which may be needed for
croup or bronchitis, should always be explained.
I have found the printed form as given below very useful not
only in making the directions absolutely plain and unmistakable,
but also as a great time-saving measure. The expense of printing-
is but a trifle. Form A represents the front of the slip. A few minutes
is all that is necessary to fill in the blank spaces. Form B represents
the back of the slip; on this the results of the preceding twelve or
twenty-four hours are entered. One chart may be made to answer
for twelve or twenty-four hours, and when the case is finished we
have a complete record, secured with the expenditure of little time
and labor.
FORM A.
. hrs.
.hrs.
. hrs.
.hrs.
.hrs.
.°F.
Date Name
Age Disease
ORDERS.
Food.
Temperature to be taken every . . . hf s.
Spray Gargle Throat with
I^ 1 every. . .hrs.
every .
I^ 2 every . . . hrs.
Irrigate Throat with
I^ 3 every. . .hrs.
every .
Whisky every . . . hrs.
Irrigate Ear with
Brandy every . . . hrs.
at . .°F., every.
Steam Inhalations every . . . hrs.
Irrigate Colon with
using
at . .°F., every.
Sponge Bath for. . .min. every. . .hrs.
Counter-irritation with
at. . .°F., if Temp, reaches . . .°F.
Mustard .... parts
Cool Pack to be given if Temp, reaches
Flour .... parts
. . .°F., and continued until Temp.
to every .
falls to. . .°F., using water at. . . .°F.
Give Enema of Soapsuds
Saline at
at . . . o'clock if necessary.
FORM
B.
Date
CLINICAL NOTES.
hour.
Temperature °F. °F. °F. °F.
^F. °F.
Pulse
Respiration
Sleep
Nourishment
Skin
Tongue
Throat
Vomiting
Lungs
Stools no. in 24 hr.
character
Heart
Abdomen
Urine amt. oz. in 24 hrs.
Nervous Symptoms
Blood
Special Symptoms
TREATMENT OF THE INDIVIDUAL
In these days of specialization, in associating with medical men
in consultation or otherwise, one is sometimes impressed with the
fact that there is a tendency for the patient, the individual, to be
lost sight of, to be overshadowed by the immediate disease or con-
42 GENERAL CONSIDERATIONS
dition from which he may be suffering. In children the success of
the treatment in practically every chronic ailment depends upon the
vitality of the individual patient and his powers of resistance as
a whole, to a much greater degree than is the case with the adult.
The object of taking up this subject is not to be unkindly critical,
but to call attention to one phase of the management of children
which is not sufficiently appreciated by many who have to deal with
them in their professional work. It is not at all infrequent to
see poorly conditioned children who have been treated for months
by local measures for a skin affection, recover without any local
treatment whatever, other than an attempt perhaps to relieve the
itching, when their lives are ordered according to the requirements
of the growing child, as regards nutrition, bowel evacuation, sleep,
suitable clothing, fresh air, and rational exercise. I have seen cases
of chronic rhinitis and bronchitis which had persisted for weeks
respond promptly when local measures, sprays and douches, and
the internal use of drugs were suspended and the child's life directed
along rational lines. Those who treat tuberculous and other chronic
bone diseases, chronic otitis, chorea, and hysteria, are to be reminded
that their work is not half finished when thev have completed the
usual daily or weekly routine treatment. In these chronic ailments
it is folly to expect — what a cure really means — a constructive
process on a destructive diet and improper habits of life. Children
possess marked recuperative powers, and the rapidity of progress
toward recovery is often most gratifying when right conditions are
instituted. It is the height of folly to give children iron for anemia
and allow them every form of indiscretion in diet. It should always
be remembered that the best results are obtained in the treatment
of a child, whatever the nature of his illness, when he has a child's
normal existence, and it is only under such conditions that satis-
factory results of treatment can be expected.
NECESSITY OF METHOD IN THE MANAGEMENT OF CHILDREN
Among the observations that have been made during my work
in pediatrics among all types and classes of people I have been
particularly impressed with the fact that some children are the
source of an immense amount of trouble, while others of no better
health or greater strength cause very little anxiety on the part of
their parents. Children diff'er greatly as regards individual traits
and disposition, but these can be fashioned to a great extent by
proper management. The more spirited the child, the greater need
of method in its care. I know mothers who are worn-out, nervous
wrecks for no other reason than a lack of system in the management
of the daily life of their children. Thorough-going conscientious
mothers they may be, but thev represent that large number of
mothers who have never been tauglit that certain functions and
THE SICK-ROOM 42
duties should be performed only at certain definite times every day.
This subject is considered not from any moral standpoint but simply
because of its bearing upon health.
Beginning with the baby at birth, he should be fed or nursed at
definite times and at no others. Sleeping should never interfere
with the nursing hours. The child should have its time for undis-
turbed repose and a midday nap should be insisted upon at a certain
hour until the child is six years old. The definite time for meals, with
properly selected food, should be continued throughout adolescence.
The child should be bathed at a certain hour and aired at a certain
hour. "Runabouts" should have their hours for play and should
retire at a definite time every evening. vSuch a regime is conducive
to perfect health, consequently to better growth and development
and to a stronger manhood. It is idle to say that many parents,
particularly among the poor, cannot conform to such requirements.
The poor are just as anxious to do the best for their children as are
the rich, and will do it to the best of their ability if the reasons for
doing it are explained to them. If they cannot reach the ideal,
they will attain to a higher degree of efficiency by striving for it.
The trouble ordinarily is not with the mother, it rests more with
the medical adviser, who is largely responsible for the ignorance of
the mother and the resulting harm to her offspring.
THE SICK-ROOM
If there is a choice of rooms for the patient, as there is in many
households, its size and means of ventilation are important points
to be considered in its selection. During cold weather a room with
southern exposure, to which the sun has free access, should be chosen.
During the hot months of summer, however, the cooler the room, the
better, provided the size and ventilation are satisfactory. The
furnishings of the room should be of the simplest, only those articles
of furniture being allowed to remain which are required for the
patient. So many of the ailments of childhood are of an infectious
nature that only articles of furniture should be used that can be
washed. Curtains, hangings, and plush furniture have no place in
a sick-room. A plain wood floor is much better than a carpeted
one. Enameled beds, plain wood or enameled chairs and tables
are best. A painted wall is much better than a papered one. A
fireplace is desirable not only for heating purposes but also for
ventilation. The successful treatment of severe illnesses in children
is often determined by the careful attention to every detail in the
care of the patient. A child ill in a dirty, badly ventilated over-
furnished, overheated room is from the first at a decided disadvan-
tage.
The Window-board. — A convenient and simple means for ven-
tilating the living-room, sleeping-room, or sick-room of a child
44
GENERAL CONSIDERATIONS
is by what is known as the window-board. A plain inch board is
sawed the width of the window-frame and placed under the raised
window in the lateral frame groove resting upon the sill. This raises
the top of the lower sash above the bottom of the upper one, leaving
a space between, through which the air enters with the current
directed upward. The board may be of any width — four, six, or
eight inches. A width of six inches is commonly used. There are
various ventilating devices in the market. Those that are of value
are expensive, and their effectiveness over the simple means above
suggested does not warrant the expenditure.
THE NEW-BORN
PREMATURE AND CONGENITALLY WEAK INFANTS
There are comparatively few infants born before the completion
of the twenty-eighth week of pregnancy that surA'ive the first year.
Reported cases of survival of those born before that time are usually
unreliable, as they seldom take the child beyond the third month.
The prognosis is influenced by the factors causing the premature
birth. If syphilis is present, the child may survive but a day or two.
Children whose births are forced because of kidney disease in the
mother do not appear to do as well as others. I have treated a
large number of premature infants in children's institutions and
have had anything but brilliant results with them. They not
infrequently live to be two, three, or four months of age or older,
but on account of their reduced vitality they readily succumb to the
slightest ailment, a mild bronchitis or fermentative diarrhea being
sufficient to terminate their existence.
In the management of the premature and delicate newly born
there are three points to be considered — the air the child gets to
breathe, the nourishment, and the maintenance of bodily heat. It is
also to be remembered that we are dealing wdth an undeveloped
body which is not ready for the environment in which it is placed.
The premature baby should be handled only when necessary, and
then in the gentlest manner. Bathing is often best omitted for
the first few weeks, oil being used for cleansing purposes. Because
of the undeveloped parenchyma of the lungs unusually good fresh
air is required. Because of the undeveloped heat-centers the body-
heat of these infants is quickly lost and must be maintained by
artificial means. The stomach is small and the digestive processes
are undeveloped and weak, so that the nourishment should be of the
most easily assimilable character.
The maintenance of heat is of the utmost importance. For
this purpose incubators and their various modifications have been
used from time to time. My experience with incubators has been
unsatisfactory. They may bv careful watching maintain an even
temperature, but all that I have used have been defective in supply-
ing fresh air to the child. My incubator babies invariably have
done badly. If the electrotherm (Fig. 5) is not at hand, the
padded crib with the child wrapped in cotton and surrounded by
hot-water bottles is the best means of maintaining the temperature.
A thermometer should rest between the cotton and the bed-clothing
as a guide to the nurses in the use of the hot-water bottles. Ordi-
45
46
THE NEW-BORN
narily this should register from 85° and 95° F., depending upon the
temperature of the child, whose rectal temperature should at first
be taken frequently. If there is a tendency for his temperature to
be greatly reduced — below 95° F. — more external heat will be neces-
sary than if the temperature w^ere 97° or 98° F. The best device
among those which I have had an opportunity to obser\'e for main-
taining artificial heat is the electrotherm advocated and described
by Holt, "Diseases of Infancy and Childhood," 1906.
"These small heaters are attached to an electric fixture, like a
drop-light. A convenient size is from ten to fifteen inches. It is
placed between two or three thicknesses of blankets, upon which the
infant lies in its basket or crib. The degree of heat can be regulated
according to the amount of electricity turned on. This mode of
handling premature infants has been given thorough trial at the
Fig. 5.— Electrotherm.
Babies' Hospital and has been found to fulfil the indications, with
children as small as three pounds and as young as seven months, quite
as well as the incubator, while at the same time being free from its
dangers. It has not been necessary to raise the general tempera-
ture of the room. These patients when kept in the wards at an
ordinary temperature have maintained an even bodily temperature
much more uniformly than with any other method I have seen, the
incubator included."
A mistake often made in the management of premature and
delicate infants is that of providing too warm air for respiration,
a glaring defect in most incubators. The best means of decreasing
a delicate child's vitahty and resistance and increasing his chances
of pulmonary infection, is to supply him constantly with air at
80° to 90° F. In a modern house the maintenance of this temperature
usually means an absence of change of air and an abundance of
PREMATURE AND CONGENITALLY WEAK INFANTS
47
bacteria. The patients do best when the temperature of the air
they breathe is from 70° to 72° F.
Breast-milk for premature infants born under twenty-eight
weeks is almost a necessity, and should always be procured when
possible for all premature children. The mother, with the rarest
exception, is unable to supply it, so that a wet-nurse should be
secured. In selecting a wet-nurse for a premature baby it is advis-
able to take the wet-nurse's baby also, as the premature infant may
not be able to nurse, or if he nurses he will not take all the milk.
Pumping the breasts of a wet-nurse will almost invariably dry them
up, if her own baby is not with her to furnish the
necessary stimulation of nursing. Sufhcient milk
may be removed by the breast-pump to supply
the premature infant if he is unable to nurse, and
the wet-nurse's baby will empty the breast. For
premature babies who refuse the breast or are un-
able to take a nipple, the Breck feeder (Fig. 6)
may be used as a means of giving nourishment,
or gavage (page 135) may be brought into use.
This I have been obliged to resort to in several
cases. The Breck feeder consists of a graduated
glass tube, narrowed at one end. Over this end
is placed a small rubber nipple, the other end being
closed by a flexible rubber cap. Drawing on the
nipple is aided and encouraged by pressure on the
air-filled cap. If the breast-milk proves too strong
it may be diluted with equal parts of a 6 percent
sugar solution, from one-half to one ounce of the
mixture being given at first at intervals of from
one to one and one-half hours. Fourteen to fif-
teen feedings mav be given in the twenty-four
hours, the amount depending upon the child's di-
gestive ability. If human milk is not obtainable,
whey made from whole milk may be given, the fig. 6.— the breck
nutritional equivalent of which is approximately Feeder.
I percent fat, i percent proteid, 5.5 percent
sugar, or one ounce of gravity cream may be given with one ounce of
milk-sugar and fifteen ounces of water, which gives a nutritional
equivalent of i percent fat, 5 percent sugar, and 3 percent proteid.
Canned condensed milk, one part, to from 24 to 30 parts of water,
may be used with advantage as a temporary feeding measure when
nothing better is available. The food strength is increased, the
intervals made longer, and the feedings larger, as the patient proves
able to assimilate the food.
The premature child requires unusual advantages, and even wlien
but one month premature, rarely "catches up" during the first year,
sometimes not for two or three years.
48 THE NEW-BORN
ASPHYXIA IN THE NEWLY BORN
The first step in the management of asphyxia in the newly born
iDaby is to clean the mouth and throat of the mucus which will
almost invariably be found there. This is best done by using as
a swab the index-finger wrapped with dry absorbent cotton or sterile
gauze. Spanking the child or the alternate use of a hot (iio° F.)
and cold (60° F.) bath, the child being rapidly transferred from one
to the other, will often stimulate respiration by inducing the child
to cry. When these methods fail, inflation of the lungs by the
mouth-to-mouth method may be attempted. Various other methods
of inducing respiration have been advocated from time to time.
The most effective are those of Laborde, Dew, and Schultze. The
Laborde method consists in making rhythmic traction on the tongue,
from twelve to fourteen times a minute, which it is claimed excites
respiration. The Dew method consists in grasping the infant by
the back of the neck Avith one hand and by the knees with the other.
The upper and lower portions of the child are then approximated
by a flexion of the thorax on the abdomen ; the reverse movement —
extension — should also be used, and thus alternate flexion and
extension are practised fifteen to twenty times a minute. Schultze's
method is described by him and quoted by Edgar as follows : ' ' The
child lying upon its back is grasped by the shoulders, the open hand
having been slipped beneath the head. The last three fingers
remain extended in contact with the back while each index-finger
is inserted into an axilla, the thumbs lying upon and in front of the
shoulders. When the child thus held is allowed to hang suspended,
its entire v/eight rests upon the two fingers in the arm-pits. It is
now swung forward and upward, the operator's hands going to the
height of his own head ; the pelvic end of the child rises above its
head and falls slowly toward the operator by its own weight, flexion
occurring in the lumbar region. The thumbs in front of the shoulders
compress the chest while the hyperflexed lumbar vertebrae and
pelvis compress the abdomen and through it the thorax; finally,
the last three fingers on each side compress the thorax laterally.
As a result of this manoeuver, when properly done, aspirated secre-
tions flow abundanth' from the mouth. The distended heart also
feels the compression which forces the blood into the arteries. The
child is now swung back into its original position and supported
entirely by the fingers in the axillae. The compression of the thumbs
and last three fingers is removed. The downward swing elevates
the sternum and ribs, while gravitation and the traction of the
intestines depress the diaphragm. It is often possible to hear the
air rush into the infant's glottis as it reaches the original position,
although this can occur in a cadaver. The amplification of the
thorax lowers the intracardiac pressure. The child should be
SEPSIS IN THE NEWLY BORN 49
swung Up and down ten times for the space of a minute. The
effects of the manoeuver should be as follows: The heart-beat
increases in frequency, the cadaveric pallor of the jikin becomes
replaced by a rosy hue, and the muscular tonus appears. The child
is then placed in a warm bath and watched. If the inspirations are
superficial, a momentary dip in cold water is indicated. If the
heart-action becomes poor the child should be swung again. If
prolonged swinging becomes necessary, the root of the tongue should
be compressed forward in order to raise the epiglottis and permit
the removal of secretions with the fingers. In premature children
the thoracic walls are often too soft to benefit by the compression
of the fingers. In these cases insufflation of air should be practised."
It is not well to rely upon one method. If necessary, different
means of inducing respiration may be attempted in a given case.
The introduction of a catheter or instruments into the larynx has
not met with favor from obstetricians.
SEPSIS IN THE NEWLY BORN
The newly born infant is peculiarly susceptible to infections,
particularly with the pyogenic bacteria. The avenues for the
entrance of bacteria into the body are many, and the resistance at
this period of life is very slight. Infection may be either through the
mouth, which is probably the most frequent portal of entry, or
through the nose, the skin, the rectum, the conjunctivae, the urethra,
the umbilicus, and, in girls, the vagina. Almost any portion of the
body may be the seat of the infection. It is rare, according to the
cases upon which I have made autopsies, to find only one organ or
structure affected. Usually two or three or more portions of the
body are involved in the septic process.
The management resolves itself into relieving the system of the
infection, as is possible when its seat of operation is the skin in mul-
tiple abscess formation ; incision should be made and followed by a wet
dressing of a saturated solution of boric acid, or, if the area is not too
large, a 1 15000 solution of bichlorid. If the site of the infection is at
the umbilicus, the suppurating surface should be thoroughly cleansed
and kept covered with a wet dressing of i : 5000 bichlorid, which
should be changed at least every two hours. If there is erysipelas,
an ointment composed of 30 percent ichthyol in vaselin makes the best
dressing. This should be freshly applied every four hours. The septic
infant, whether the infection is mild or severe, usually nurses very
poorly. Oftentimes both breast and bottle are refused. When a
sufficient amount of fluid is not taken, plain boiled water or sugar-
water, 5 per cent, or completely peptonized skimmed milk, may be
given by gavage. If fluids are not given, the child is very apt to de-
velop inanition fever, which, added to the infection, makes a serious
condition more serious. From two to four ounces of a normal salt
4
50 . THE NEW-BORN
solution used lukewarm, injected into the descending colon through
a catheter, will often be retained with beneficial results. It should
not be repeated oftener than once in six hours.
Medication other than small doses of alcohol — five drops of
brandy, well diluted, every hour if necessary — has been without
avail in my cases. The prognosis at best is very grave, although
when the vital organs are not involved, cases occasionally recover.
An unusual case of infection which ended in recovery occurred
in my private practice. The child had no fever, but lost rapidly
in weight. There was marked prostration. The skin took on a
greenish hue and we were at a loss to discover the cause of the illness.
The infection was suspected, but no portal of entry could be found,
neither could we find any localized process until the nurse discovered
that the umbilicus and the skin about it were bathed in pus. The
umbilicus had apparently healed without any indication of local
trouble. Investigation showed, however, that the infection had
entered at this site, and extending along the vein or artery, had
become pocketed and formed an abscess one and one-half inches
deep. Enlarging the opening at the umbilicus and establishing
free drainage were followed by a gradual closure of the abscess
cavity and recovery.
CEPHALHEMATOMA
A cephalhematoma is a blood tumor situated between the peri-
cranium and the exterior of one or more of the bones of the skull.
The tumors vary considerably in size, are readily recognized, and are
situated at the site of the caput succedaneum. In a small proportion
of the cases an internal tumor occurs at the same time, the effusion
taking place between the dura mater and the skull. Very rarely
suppuration occurs in the tumor. I have seen two cases of this
nature, both of which recovered under incision and antiseptic dress-
ings. If there is an internal effusion the case will be fatal. One of
these has come under my observation. The usual course, when the
tumor is external, is for it to be absorbed without treatment.
ICTERUS NEONATORUM
Jaundice occurs in about one-third of all infants. It usually
makes its appearance on the second or third day and lasts from a
few days, in mild cases, to a week or ten days, in severe. Its effect
on the child is practically nil. At the New York Infant Asylum
the records show that the icteric infants thrive as well as those who
are entirely free from the complaint. It is well in these infants to
keep the intestinal tract active. If the bowels do not move freely,
twenty drops of castor oil should be given and repeated in twenty-four
hours, if required.
UMBILICAL POLYP ATELECTASIS 5 1
UMBILICAL POLYP
An umbilical polyp is usually the result of an overgrowth or an
outgrowth of a neglected granuloma. The mass, which may vary
in size from a flaxseed to a pea, is reddened, moist, and usually
bathed in a viscid muco-purulent secretion. There is often con-
siderable excoriation of the skin about the umbilical opening.
Sometimes the mass is so small that it is hidden by the overlapping
folds of skin, and its presence would not be suspected but for the
secretion which keeps the parts moist. The polypi are very vascular.
Cutting the pedicle and applying nitrate of silver or carbolic acid is
not a safe procedure. I have known severe hemorrhage to follow
such treatment. About ten years ago I was obliged to sit for three
hours by the side of a crying, wriggling child making pressure on the
cut stump of an umbilical polyp, after a colleague had cut the pedicle.
In no other way could the hemorrhage be controlled. The best
means of management in these cases is to ligate the pedicle and
allow the polyp to wither and drop off. The powder referred to
under the head of Granuloma should be applied after the ligature
is fixed, and reapplied frequently before and after the polyp has
dropped off, and continued until the wound is cicatrized and dr\\
ATELECTASIS
Atelectasis may be present in the newly born who come into the
world asphyxiated, and it is not infrequently seen when there has
been a prolonged difficult delivery. It may be the result of weak-
ness, pure and simple, and is not of unusual occurrence in the pre-
mature. For some reason there is a failure or inability to dilate the
air-vesicles. I have seen sudden collapse occur in marantic infants,
the child dying in a few moments with cyanosis and orthopnea,
the autopsy proving the diagnosis of atelectasis. The condition
may be produced also through compression of the lung with exuda-
tion in pleurisy or by the obstruction of a bronchus with mucus.
The most dangerous types are those in which it is present in the
newly born and when it occurs in the weakly during early life. The
warning of its presence is usually in the form of cyanosis with rapid
superficial breathing with or without convulsions.
The management of atelectasis in the newly bom, who come into
the world asphyxiated because of prolonged difficult delivery or
when it is the result of weakness, is to make the child cry lustily.
If auscultation over the lower lobes posteriorly does not show free
vesicular breathing, the child should be made to cry every day,
either by spanking, or by plunging him first into water at 1 10° F. and
again into cold water at 60° F., our object being to induce vigorous
crying and thus dilate the air-vesicles. A case under treatment at
the present time is making satisfactory improvement by inhaUng
52 THE NEW-BORN
oxygen for one minute out of every fifteen, with stimulation of
various kinds to make him cry. Atelectasis from obstruction of a
bronchus or from compression is usually readily relieved when the
source of the trouble is removed. In out-patient work we occa-
sionally see marantic young infants in which there is an involve-
ment of a considerable area of one of the lower lobes posteriorly
without any sign whatever of discomfort. The process of resolution
in these cases is very slow, from the periphery toward the center.
The condition is probably of much more frequent occurrence than
is generally supposed, if we are to judge from the autopsy findings
in young infants, particularly in institutions.
MASTITIS IN THE NEWLY BORN
Inflammation of the breasts in the newly born, both in the male
and in the female, is seen with considerable frequency in out-patient
work. The mammary glands may be swollen to several times their
normal size and acutely tender. These glands, in young infants,
should not be pressed or manipulated in any way, more than is
required for cleanliness. Not a few of my out-patient cases of
mastitis have been due to the attempts of the midwife to express
the milk from the breasts. The cases are explained by the fact
that the opening of the nipple is large and the gland readily becomes
infected from unwashed hands or unclean wearing apparel. My
cases have usually responded well to the application of ichthyol
25 percent in oxid of zinc ointment, U. S. P. The ointment is
spread generously upon old linen, which has been boiled and dried,
and is then gently bound upon the inflamed gland. Over this is
placed oiled silk to protect the clothing, and, over all, a gauze
bandage is applied with very light pressure. The dressing should
be changed and fresh ointment applied every six hours. In four
of my cases the mastitis was beyond control when first seen and
suppuration of the gland — mammary abscess — followed.
Mastitis in Young Girls. — Inflammation of the mammary
gland in young girls is a comparatively rare condition, but one of
sufficiently frequent occurrence to require mention. Swelling and
tenderness of the breasts are often complained of by young girls
about the time of puberty, but they subside without treatment if
let alone. Mastitis is usually due to the entrance of bacteria through
the nipple, and in its clinical manifestations it resembles mastitis
in the adult, except that the entire gland is usually involved, becom-
ing swollen, tender, and excruciatingly painful. Two of these cases
have been under my care during the past year ; one in a girl of thirteen,
the other in a girl of seven years. Both cases responded to the use
of an ice-bag during the acute stage, which was kept constantly
applied during the waking hours. At night a wet dressing of bichlo-
rid of mercury, i : 5000, was kept on the infected glands. There
HEMORRHAGIC DISEASES OF THE NEWLY BORN
53
was moderate fever, headache, and lassitude in both patients. Each
was given a saline laxative in the form of citrate of magnesia, and
a diet of broth, gruel, toast, and stewed fruit. This diet was con-
tinued during the period of fever. In one case recovery occurred
in five days and in the other in seven days.
Mammary Abscess in Infants.— Mammary abscess is the result
of a mastitis which failed to undergo resolution. It occurs as fre-
quently in males as in females. All of my cases were seen in
institutions or in out-patient work. In four, the abscess developed
under my own observation. In a female child, a patient at the
New York Infant Asylum, both glands were entirely destroyed.
As soon as pus is discovered the abscess should be incised and
drained, with a view to saving as much of the gland as possible.
Of course, this advice applies particularly to a female patient. Wet
dressings are not applicable in cases of young infants when the parts
covering the thorax or abdomen are involved. It is my custom to
protect the skin from infection by the use of a lo percent boric
acid ointment in cold-cream as a base. This is applied on old linen
about the abscess opening. The dressing should be changed three
times daily.
UMBILICAL GRANULOMA
A granuloma at the umbilicus consists of a reddish secreting
mass of granulations comprising the umbilical stump. It may
vary in size from the head of a pin to a pea. Granulomata usually
occur in cases in which the care of the cord has been neglected.
In out-patient work they are very frequently seen, and occur usually
in children who have been delivered by midwives. The mother
brings the child to the dispensary with the story that the navel
will not heal.
The granulations are very vascular and bleed readily. After
thoroughly cleansing the parts, one or more applications of a 50 per-
cent nitrate of silver solution, followed by the free use of an absorbent
dusting-powder, soon produces a normal cicatrix. A powder of
the following composition is recommended :
I^. Acidi salicylici gr. xv
Acidi borici gr. xxv
Pulveris zinci oxidi
Pulveris amyli aa 5 j
The powder should be applied very freely at two-hour intervals
during the day, or at least often enough to keep the wound dry.
HEMORRHAGIC DISEASES OF THE NEWLY BORN
A considerable number of these infants have come under my
observation at the New York Infant Asylum. In describing the
condition it would seem unnecessary to continue an irrational
54 THE NEW-BORN
nomenclature still in use, based upon the location of the hemorrhage,
or the name of the physician who is believed to have given the first
description of a symptom-complex which is supposed to characterize
the disease. I have seen hemorrhages in the newly born occur from
nearly every portion of the body and into most of the internal organs.
In a recent case a colored infant bled to death in the pericranial
tissues without a sign of hemorrhage elsewhere. I have seen fatal
hemorrhages from the navel which we were not able to control.
vSyphilis and hemophilia play an insignificant part in causing the
hemorrhage. Sepsis is a broad term that covers the etiology of
these cases. Oftentimes there are other proofs of the infection
aside from the hemorrhage. Because infections differ in degree,
nature, and field of action does not necessarily call for a typical
description of each form of infection, and with our limited knowledge
of the infectious process which may cause the hemorrhage, this is
impossible at the present time. Without doubt different forms of
infection may enter the circulating medium of the newly born with
a result in hemorrhage. The cases resemble hemophilia in the
persistence of the bleeding, while infrequently disproving its exis-
tence by making a complete recovery. The use of styptics and
astringents for controlling the hemorrhage is useless. The only
measure that has assisted me in any way has been the application
of pressure to the bleeding parts, and this is not possible in many
situations. Adrenalin, locally or by internal administration, has
not been of any appreciable service. Our best results, which were
by no means satisfactory, were obtained by attention to the gastro-
enteric tract and in supplying the best possible means of nutrition.
TETANUS NEONATORUM
Tetanus in the young infant is fortunately of very infrequent
occurrence. From the second to the ninth day is the usual period
of the development of the disease, although it may appear as late
as the fourth or fifth week. Recovery is the exception. But few
cases live longer than the second day of the illness. The treatment
is by the use of sedatives such as chloral and the bromids. One
grain of chloral every two hours appears to exert some temporary
benefit. Targe doses of bromid of soda— eight to ten grains — ad-
ministered by the rectum every three hours in mucilage of acacia
have given good results according to some observers. Tetanus anti-
toxin has not been used in a sufficient number of cases to establish
any facts relating to its value. The nutrition of the patient is best
maintained by the use of peptonized milk given by gavage.
The cord stump should be cauterized in order to destroy any
tetanus bacilli which may be present and a wet dressing of i : 5000 of
bichlorid of mercury kept constantly applied.
NUTRITION AND GROWTH
The fundamental principles in the life of the young of all animals
are growth and development. This statement applies to the young
of the lower animals as well as to man. Nature has fixed and
definite laws in accordance with which this growth and development
proceed. The type of animal produced depends in no small degree
upon the way we follow out Nature's laws.
Heredity is, of course, an important factor, but environment
counts for more. The young of the lower animals or of man may
possess all that can be desired in the way of heredity, but if the
later management of his life is faulty, an adult is produced which is
almost certain to fall short of the normal. On the other hand,
another, without the benefits of a good heredity, when given the
advantages of faithful scientific care may produce an adult decidedly
superior in all respects to those more fortunate in birth. I have
seen this demonstrated time and again, both in the lower animals
and in man. From my earliest recollection I have carefully watched
the growth and development of animals. By observing care as to
feeding, housing, ventilation, cleanliness, and exercise, I have seen
animals which promised but little at birth develop into perfect
mature specimens of their kind. During the past eighteen years
I have been intimately associated with thousands of infants and
growing children in private, in hospital, and in out-patient work.
The possibilities of proper growth under good management when
little was to be expected, judging from the original condition of the
patient, have been impressed upon me repeatedly.
The child is here through no choice of his own. He is to have
a future. His health, vigor, powers of resistance, happiness, and
usefulness as a citizen are determined in no small degree by the
nature of his care during the first fifteen years of life. He has a
right to demand that such care be given him as will be conducive
at least to a sound, well-developed body, and this should be our
first thought and object regarding him. Consider for a moment the
number of occupations, other than the army and the navy, which
require physical fitness before a candidate is accepted. Competi-
tion is keen at the present time and will be keener in the future.
Employers of men and women, whether in the office, the factory, or
on the farm, cannot afford to employ the physically weak.
The most important factor in the making of men and women is
nutrition. It requires no great power of reasoning to appreciate
the fact that the child who is fed on suitable food will become a
55
56 NUTRITION AND GROWTH
more vigorous, better developed adult than one who, beginning with
his birth and continuing throughout the entire period of his growth,
is given only food possessing indifferent tissue-building qualities.
Next in importance to food, and following in close succession, are
fresh air, cleanliness, cheerful surroundings, and healthful amuse-
ments, together with an absence of work of an arduous nature,
whether in school or at service. That the offspring of man suffers
more from nutritional errors due to the lack of suitable care than do
the young of the lower animals is lamentable, but it is a fact never-
theless. The absence of thought and care and of knowledge relating
to children is due to the fact that the child as such has apparently no
intrinsic value in dollars and cents, whereas the young of the lower
animals are no small part of their owner's material possessions.
Success in the management of children, nutritionally and other-
wise, means daily attention to detail. Feeding the child properly
one or two months out of the year is of little value. He should be
fed properly every day in the year, for under normal conditions
every day is a day of growth. Another factor having a deterrent
influence upon the development of children is their unfavorable
start during the first year. Unfortunately many mothers cannot
supply to the infant the nourishment to which he is entitled, and this
brings us to the matter of substitute feeding, fraught with its per-
plexities and uncertainties in the most competent hands, and with its
dangers and disasters with the incompetent and inefificient. In the
chapter on Substitute Feeding in infants their nutrition is consid-
ered in detail. It is sufficient to remark here that Nature has
provided for the baby a food which contains the nutritional elements,
fat, sugar, and proteid, in fairly definite proportions and in peculiar
forms. Success in substitute feeding depends upon our ability to
supplv in suitable forms, and the child's ability to assimilate, a food
containing approximately the quantities of the nutritive elements
found in human milk. An exact reproduction of mother's milk by
the use of cow's milk or other food is, of course, impossible, ^^'e can
imitate it, however, with sufficient accuracy to make it an acceptable
and sufficient food for most children who are deprived of the breast.
Mtev the nursing or the bottle age, the feeding must not be left to
the family judgment, for at this rapidly growing period suitable
nutrition is most important. Left to the family, the diet during
the second year is very apt to consist of milk, which in large cities
is often of uncertain nutritive value, together w4th insufficiently
cooked cereals, boxed breakfast foods, bread-stuffs, crackers, and
cake^often procured at the grocer's or baker's. At the out-patient
departments of the New York Babies' Hospital and the New York
Polyclinic Medical School only 20 percent of the children treated
who are over one year of age are of normal development. In those
under one year of age, only 35 percent are normal. \\'hile these
NUTRITION AND GROWTH 57
children are not to be considered as representing the country as a
whole, still they do represent a large part of the population of our
larger cities. These children are the offspring of day-laborers,
drivers, waiters, and small wage earners generally. They have
been fed in the manner above described, not because of poverty, but
because of an absence of the slightest knowledge on the part of the
parents regarding suitability of foods. Their children were not
hungry, they were fed to satisfy the appetite, but when that was
accomplished the parents considered their duty done. To feed with
a definite purpose — with a view solely to the physical development
of their children — had never entered the minds of the parents, yet
most of them could read and write and possessed a fair degree of
general intelligence. They were conversa'nt with affairs and had
attended the public schools, but were absolutely untaught as to how
they should live.
The diet during this period of child life should be highly nutritious,
and, in order to be properly digested, food should be given at definite
intervals. The habit of allowing children to eat between meals
cannot be too strongly condemned. It not only spoils the appetite
for suitable food at regular hours, causing children to crave delicacies,
but prevents the most complete digestion and assimilation. The
active "runabout" child and the school-child require a high proteid
diet. It should consist of red meat, never oftener than once daily,
poultry, fish, eggs, milk, butter, cream, whole-wheat bread and
cereals, such as oatmeal, cracked wheat, commeal, and hominy.
Other cereals may be used for the sake of variety. Each cereal
mentioned should be cooked three hours the day before using.
It may be claimed that the prolonged cooking is impossible to secure.
It is done, however, in dozens of families under my professional
care. Green vegetables and stewed and raw fruits are important
adjuncts to the dietary. Dried peas, beans, and lentils in the form
of a puree, are valuable articles of nutrition because of their large
percentages of vegetable proteid, and they are particularly useful
in children with a rheumatic tendency, in whom the use of red meat
must be curtailed.
Doubtless the next most important factor after food and the
means of giving it, is good air. It is a just criticism of the average
American that he is afraid of fresh air, not only by night but by da}^
and it is one of the most difficult features of a child's management
with which I have had to deal. Mothers will feed the children in
detail according to instruction. They will bathe them and follow
out to my satisfaction every order and direction. The stumbling-
block is the open window. If the mother opens it as directed, the
grandmother or some other member of the family appears on the
scene and closes it. The window-board (page 43) and other means
of ventilation on the market have their uses. The window-board in
58 NUTRITION AND GROWTH
my hands has been most satisfactory. It is to be hoped that a
knowledge of the means and results of treating tuberculosis by
open-air methods, and the recent agitation concerning the treatment
of pneumonia and other infectious diseases along similar lines, may
so permeate the minds of the masses as to quiet their fears regarding
dangers of outdoor air.
In my own experience I have been able to secure an ample supply
of fresh air either by the window-board, already referred to, or the
open fireplace. When the ehild is out of the liying-room or nursery,
the room is ventilated by opening all the windows, when family
conditions allow, the nursery always being aired in this way. The
sleeping-room should always be aired for one hour before the child is
put to bed. Indoor airing (page 37), for which the child is dressed
as for going out, placed in his carriage or cart, and wheeled up and
down the room for an hour or two with the windows wide open
regardless of the weather, is most satisfactory in very young and very
delicate children, and during convalescence from illness. On very
inclement days the child accustomed to his daily outing will be greatly
benefited by the indoor airing.
With bathing we have less to complain of. The necessity for the
daily bath is appreciated and acted upon by nearly all classes of
society. From the time the cord falls and the cicatrix forms, the
well infant and child should have one tub-bath daily. If he is too
ill for the tub, he is not too ill to be sponged. The well child is
naturally good-natured and happy. When such is not the case,
we have not a well child to deal with. Something is wrong. Often-
times it is the home management. Adults often forget that exuber-
ance of spirits and thoughtlessness belong to childhood. Persistent
child-nagging becomes a habit with many parents and teachers;
in fact, irritable mothers usually have irritable children. Work
involving strain, whether physical or mental, should form no part
of the life of the child. In our modern school system the forcing
process, the competitions, the giving of rewards of merit, are all of
them pernicious practices. As a result of the competitive system,
progress, to be sure, is made along intellectual lines, but at the
expense of the physical, and what does intellectual attainment count
for in a weakly or diseased body? A child cannot do hard mental
work, such as is required of many children from the tenth to the
fifteenth year, and be expected at the same time to develop to the
best advantage physically. The appetite and digestive powers, the
capacity for taking and assimilating food, are diminished as a result.
I have seen it in hundreds of cases. On the streets in New York
two pictures always fill me with pity — one is the pale, slender school-
girl struggling home with a load of books. Such a child who came
to me during the past year had eleven text-book studies besides
piano and dancing lessons! When the question is asked the child
GENERAL PROPERTIES OF FOODS 59
or the parents as to the why of all this work and worry and the close
confinement which it entails, the reply almost invariably is that all
the girls of her age do the same and she does not want to be behind.
The other picture is the "little mother," — a pale, wan, tired child
from seven to twelve years of age who "minds the baby" and the
other younger members of the household while their mother is away
from home or at work. Children so abused are happily growing
fewer, owing to various factors which need not be discussed here.
It is needless to say that neither type of child makes the ideal woman
or mother in any station in life. The condition of boys who work
in factories, sweat-shops, or elsewhere is no better. When too
much energv is expended in work, it cannot go to the building up of
a strong normal body. The State is the loser and the child is robbed
of his birthright.
It is the duty of physicians having children under their care to
explain in detail to parents their responsibility as regards the physical
welfare of their children. Parents, as a rule, are ignorant as to a
child's management; but they are anxious and wilhng to do the
best things possible for their children, and will carry out suggestions
if we take the trouble to enlighten them as to their errors.
GENERAL PROPERTIES OF FOODS
Substances used as foods, regardless of the animal which they
may nourish, possess the common property of being composed of fat,
proteids, carbohydrates, mineral substances, and water in varying
proportions. The purposes that these serve in the animal economy
are essentially the same in all forms of animal life. In order to
determine the food- value of any substance, a chemical anahsis
which shows the quantities of these nutritional elements is required.
It will be found that foods varying widely in appearance and physical
properties are still similar in that the}^ are composed of the same
food elements, although in different proportions.
Foods used to sustain animal life in any form must contain the
ingredients needed by all animals, and they must be present in a
form suited to the particular kind of animal to be fed, whether it- is
man or one of the lower animals.
The Ingredients of Foods. — All foods are composed of fat, carbo-
hydrates, proteids, mineral substance, and water, but these elements
exist in widely differing formes. Fat may be supplied in meat,
cream or milk, butter, oleomargerine or butterine, lard, olive oil,
cod-liver oil, linseed oil, cottonseed oil. etc. Carbohydrates may
be furnished in the form of cane-sugar, milk-sugar, maltose, and
dextrose-soluble products derived from starch, cornstarch, wheat or
other flour, oatmeal, rice, hominy, bread, potatoes, etc. Proteids
are secured in the form of lean beef, lamb or pork, chicken, fish, the
gluten of such cereals as wheat and oats, and also in large quantities
6o NUTRITION AND GROWTH
from peas, beans, lentils, and other legumes, from the curd of milk,,
and also from eggs. The mineral substances of food are found
combined with the other ingredients in the form of lime, phosphates,
magnesium, etc.
The Function of the Food Elements. — The proteids of the food
are used to form the bodily structures and to replace tissue consumed
by the vital processes and excreted as urea. The vital processes, such
as the circulation of the blood, respiration, and contractions of the
muscles, call for energ}^, and this together with bodily heat must be
supplied by the fats and carbohydrates. The mineral substances
are used in the formation of bone and teeth, while the water serves
to dissolve the food elements after they have been digested and to
carry off waste products.
The Advantage of a Knowledge of the Composition ot Foods. —
Inasmuch as each food element has a special function to perform,
and since growth is impossible without a sufhcient supply of these
nutritional elements, particularly the proteid, it is essential to know
within reasonable limits the composition of a food, because if the
elements are not present in proper proportions, disappointing results
may be obtained from their use which will appear inexplicable, but
which will readily be accounted for if we know what element of the
food is at fault. For these reasons it is coming to be the practice,
in infant-feeding especially, to speak of the percentage composition
of the milk -foods, as, for example, a food containing 4 percent fat,
7 percent carbohydrates, 2 percent proteids, and 35 percent min-
eral substances. Knowing from wide experience the percentages
of these ingredients generally needed in a food if it is properly to
nourish a child, it becomes possible to know in an instant whether
an infant is having a food of suitable nutritive value, by comparing
its known composition with that established by experiment, as
requisite.
The Selection of Food. — In looking over analyses of foods many
substances will be noticed which, according to their chemical com-
position, have the same food-value, but which common sense tells
us are not interchangeable. For instance, no one would attempt to
feed cracked oats to a human being unless thoroughly cooked, but
he would give them raw to the lower animals. They will nourish a
man or the animal equally well, but for man they must be prepared,
while the horse, for example, can utilize them in their original state.
This illustrates the importance of adapting food to the consumer.
Often the question in feeding is not so much, Is the food nutritious?
as, Can the patient assimilate it? Oftentimes success in infant-
feeding lies in the physician's ability to discover a form of fat,
carbohydrate, and proteid which the infant can assimilate. In the
following pages feeding measures for temporary use will be found
which may not conform to what some may consider strictly scientific
GENERAL PROPERTIES OF FOODS 6 1
principles; yet they often give brilliant results. Looking a little
below the surface, it will be found that the measures suggested are
not unscientific, and that the results are due to applying the fixed
principles of nutrition in perhaps novel or unusual ways. It is
usually best to follow the most direct route to any place, but when
this is badly blocked, it is better to go another way, if there is one,
rather than not to arrive at one's destination.
General Properties of Milks. — \\'hen most young animals are
born their digestive organs are in a more or less embrvonic condition,
and it is several months before they entirely outgrow this state.
During this period the nourishment is supplied by the mother
through her mammary glands, first as colostrum and later as milk.
When these secretions are analyzed they are found to consist of fat,
carbohydrates, proteids, mineral substances, and water, and in this
respect they do not differ from other foods. But the elements exist
in the secretion in peculiar forms, and the natural inference is that
in some way they must be particularly suited to animals whose
digestive organs are still undeveloped.
The digestive secretions of the stomachs of all known animals
contain pepsin and hydrochloric acid. In the very young these
secretions are feeble, but as development proceeds they are much
more abundant. To understand milk as a food one must know the
effect upon it of pepsin and acid. When pepsin is added to tepid
cow's milk it causes the milk to gelatinize, with the formation of curd
or junket. If the milk is slightly acidified or soured, the curd formed
is dense and solid and more difficult of digestion. When the milk
of the cow or the ass or human milk is treated with pepsin and acid
in exactly the same way, curds totally different are formed, and as
the human digestive organs are different from those of the cow or
the ass it is believed that these differences in the digestive properties
of milks are for the purposes of making the milks suitable for the
different kinds of digestive tracts. Milks may be regarded as special
forms of food which require greater digestive effort as the digestive
secretions of the stomach become stronger, and thus solid food is
furnished to the developing stomach. It is that portion of the
proteid of the milk called "casein" that is changed into a solid by
the pepsin of the stomach. The term casein, however, has been
loosely applied to all the proteids of all milks. The caseins of all
milks are not alike in their digestive properties. Therefore the
mistake of so considering them should be guarded against. A
consideration of such a modification and adaptation of cow's milk
as will make it acceptable to the infant's digestive possibilities will
be found in the chapters dealing with Substitute Feeding.
62 NUTRITION AND GROWTH
MATERNAL NURSING
Writers on this subject are very apt to state that the abihty of
the mother, particularly among the well-to-do, to fulfil this most
important function is surely decreasing. This may have been a true
statement a decade ago ; at the present time, however, 1 am sure it
is erroneous. In my own medical life I have seen a change for the
better, particularly during the past five years. The young mother
of today is better able to nurse her offspring than was her sister five
or ten years ago. I attribute this to the fact that the youth of the
present day are more vigorous, more nearly normal individuals than
were those of a decade ago. The inability to perform the nursing
function so that it will be successful has always been attributed to
the mother per sc. This, I think, is an error. Not every breast-
milk for two or three weeks after parturition is ideal, as I have found
by the examinations of hundreds of them. If a child is bom with
a generally enfeebled vitality, it keenly feels any slight abnormality
in the milk, or it may not be able to digest perfectly normal milk ;
in either event, the milk disagrees and the nursing is discontinued.
Breast-milk during the first two or three weeks of the infant's life
is produced under conditions which are unfavorable — conditions
which do not indicate the possibilities of the breast as a secreting
organ. Following, as it does, upon the stress of confinement, it is
not indicative of what may be possible later when the customary
life and daily habits are resumed. Repeatedly I have found a very
high fat or a high proteid, or both, during the first week or two,
entirely corrected later without interference. This condition at
the time was considered sufficiently serious to warrant the discon-
tinuance of nursing on the part of a weakh^ infant, while in a vigorous
infant it would be entirely ignored.
The change which enables more mothers successfully to nurse
their infants is due to two causes — more vigorous fathers and mothers
and more vigorous offspring. Following this line of reasoning, the
more normal the mother, the better able is she to perform this
normal function. That this is the case is due, I beheve, to the fact
that growing girls and young women are leading more hygienic
lives than formerly. The making of golf, bicycle and horseback
riding, boating, and automobiling popular and fashionable — in short,
the taking of girls out of doors and keeping them there a consider-
able portion of the day — has worked a marvelous change for the
better, both physically and mentally. A neurotic mother makes
the poorest possible milk-producer. Proportionate to the population,
there are fewer neurasthenics among the young women today than
there were ten years ago, and there will be still fewer ten years hence.
At the present time the timid, retiring young woman of the neuras-
thenic type is not popular in her set. It is a fortunate thing for the
MATERNAL NURSING 63.
future of the human race, at least for that portion of it which resides
in the United States, that the young woman has transferred her alle-
giance from the crochet and embroidery needle to the golf club. It
may be said that our argument holds only with the wealthy or the
well-to-do. Imitation is one of the strongest characteristics of the
human race, and this tendency in America to outdoor hygienic living
pervades all classes. vSaturday half-holidays, the excursions and
outings afforded by reduced rates in transportation, are much more
popular than they were ten years ago. Food is better selected and
better prepared, owing to increased knowledge on the part of the
people as to what constitutes proper nutrition. These are facts,
in spite of the sensational novelists and magazine-writers.
A feature which marks an important advance in the right direction
is the establishment of a department in dietetics and food economics
in the New York Training School for Teachers. The Dean, Dr. James
E. Russell, in establishing this course is producing benefits which per-
haps are more far-reaching than he realizes. The students are taught
food values, food preparation, and food economics, which consists in
providing for a given amount of money the most nutritious food in its
most attractive form. Hundreds of teachers are sent out from this
institution every year to take their places of usefulness as instructors
of the young in all portions of the country. Each has learned some-
thing of food values, and, better still, each has had impressed upon
him or her the importance of the proper nutrition of a growing
child. They are taught that, without this, the best possible type
of adult cannot be produced. As a result of such instruction they
wall be of far greater service in their fields of labor ; for not only can
they teach what is laid down in the books, but, what is equally if
not more important, they are competent to teach those under
their care how to live; and those who live properly, grow properly,
following out the maxim of Herbert Spencer that "the first requisite
for success in life, is to be a good animal; and to be a nation of good
animals, is the first condition of national prosperity." It may be
thought that we have wandered far from our subject — maternal
nursing, but such is not the case ; for conditions which relate to this
important function, even remotely, demand our respectful consid-
eration. The food and care of the growing girl have the most intimate
bearing upon her future life, and if she is to be called upon to per-
form the most important function of womanhood, she surely has the
right to demand that she receive during her girlhood proper prepara-
tion, which heretofore has too often been denied her.
It is not pleasant to criticize physicians ; but friendly criticism
should always be welcomed. The family physician does not, in a
great majority of instances, fulfil his function, or extend his field of
usefulness to its full capacity, his conception of duty too often in-
cluding only the sick. Unsought advice as to the feeding and daily
64 NUTRITION AND GROWTH
habits of a child's hfe, I find are usually welcomed and appreciated by
the parents. In practically every instance, according to my obser-
vation, errors in a child's management are due to ignorance. Parents,
no matter what their station in life, are glad to do what is for the best
interests of their children when it is made clear to them. It is our
duty to take parents into our confidence and explain to them the
reasons for the line of action advised. When they appreciate the
reason for certain procedures, I find that they are far more apt to
follow them. I am confident from observations upon many cases
that if I could have the physical direction of ten average girls in any
station in life, provided that they could have the benefit of fresh
air and good food from infancy to adolescence, successful nursing
mothers could be made out of eight of them. Certain rules of
life having a direct bearing on nursing lead us nearer the ideal and
may enable one who otherwise could not nurse her child to do so
successfully. These requirements, it will be seen, are laid along
common-sense lines and cause no hardship or mental distress — one
of the chief requirements of a nursing woman being that she shall
be mentally normal.
There are few conditions in which we are called to act so variable
and so uncertain as is the production of breast-milk. Breast-milk
is one of the most precious substances. It is invaluable unless we
can put a value on human life. The most successful nursing age is
between the twentieth and thirty-fifth years. I have, however,
seen it successfully carried on in a girl of fourteen, in a woman of
fifty- two, and in the much abused society girl, while I have seen
it fail absolutely in peasant women fresh from the fields of Hungary
and Bohemia. I have seen those in whom at first the nursing was
most unsatisfactory, develop into perfect nurses.
Some mothers will be able to carry on the nursing for only two
months ; others, three, five, seven, or nine months. In my experience
whether in out-patient or in private practice, it is extremely rare
for the breast-milk to be sufficient for a child after the ninth
month.
The following can be laid down as nursing axioms :
A diet similar to what the mother was accustomed to before the
advent of motherhood should be taken.
There should be one bowel evacuation daily.
There should be from three to four hours daily spent in the open
air with exercise which does not fatigue.
There should be at least eight hours' sleep out of every twenty-
four.
There should be absolute regularity in nursing.
There should be no worry and no excitement.
The mother should be temperate in all things.
The Diet. — I have many times been consulted by nursing mothers
MATERNAL NURSING 65
because the nursing was unsuccessful or a partial failure, and have
found that their diet has been restricted to an extreme degree.
To put on a greatly restricted diet a robust young mother who has
always eaten bountifully of a generous variety of foods is one of the
best means of curtailing the quantity and lowering the quality of
her milk-supply. \A'hen asked to prescribe a diet I tell them to eat
practically as they were accustomed to before the advent of preg-
nancy and motherhood. That this particular vegetable or that par-
ticular fruit should be forbidden on general principles is a fallacy.
Food that the patient can digest without inconvenience is a safe
food so far as the nursing is concerned, as may readily be determined
in any given case. If a wide range of diet is prescribed in some
individuals, a plain, more or less restricted diet is desirable in others.
This must be remembered in the management of the wet-nurse
(page 74). Many a wet-nurse who has been carefully selected,
who to the best of our judgment should prove satisfactorv, utterly
fails in a few days to fulfil the duties of the office for which she was
chosen. In not a few instances the failure is due to a very full diet
of unusual articles of food, the existence of which, in many instances,
she never dreamed of. Indigestion and constipation follow, and
both the nurse and the baby are made ill and the woman's usefulness
ceases. A woman who has lived and kept well on the diet and food
found in the home of the laboring-man, whether in the city or country,
will make a far better wet-nurse on this diet than if she indulges in
food to which she is entirely unaccustomed. The diet of a nursing
mother, then, should in general be as above stated.
Nursing is a perfectly normal function, and a woman should
be permitted to carry it out along only natural lines. Inasmuch as
there are two lives to be provided for instead of one, more food,
particularly of a liquid character, may be taken than she may have
been accustumed to. It is my custom to advise that milk be given
freely. A glass of milk may be taken in the middle of the afternoon
and eight ounces of milk with eight ounces of oatmeal or cornmeal
gruel at bedtime, if it does not disagree with the patient. Our only
evidence that a food is not disagreeing is the condition of the digestion.
When any article of food disagrees with the mother, or if she is
convinced that it disagrees, whether or not such is really the case,
the food should be discontinued. In a general way, milk in quan-
tities not over one quart daily, eggs, meat, fish, poultry, cereals,
green vegetables, and stewed fruit constitute a basis for selection.
The method of preparation for the different meals is not arbitrary.
The Bowel Function. — A very important and often neglected
matter in relation to nursing is the condition of the bowels. There
must be one free evacuation daily. For the treatment of constipa-
tion in nursing women I have used different methods in many cases.
The dietetic treatment does not promise much. For here, again,
5
66 NUTRITION AND GROWTH
manipulation of the diet may interfere with the milk production.
Three methods are open to use — massage, local measures, and drugs.
Massage is available in comparatively few cases. Local measures
consist in the use of enemas or suppositories. Every nursing woman
under my care is instructed to use an enema at bedtime if no evacua-
tion of the bowels has taken place during the previous twenty-four
hours. Many out-patients, in whom constipation is very prevalent,
indulge in excessive tea-drinking, taking often from one to two
gallons of tea daily. In such patients where an absolute discon-
tinuance of the tea-drinking is often impossible and not absolutely
necessary, I usually allow two cups a day. For a laxative in such
cases and in many others, a capsule of the following composition
has served me well:
I^. Extract! belladonna? gr. ^
Extract! nucis vomicae gr. i
Extract! cascara; sagrads gr. v
M. et ft. capsula No. j.
Slg. — To be taken at bedtime.
The amount of the cascara sagrada may be varied as the case may
require. In not a few instances I have found it necessary to give
two capsules a day in order to produce the desired result. Neither
the belladonna, the nux vomica, nor the cascara appears to have
any appreciable effect on the child.
Air and Exercise. — Outdoor life and exercise are desirable here
as they are under all other conditions. In a nursing woman with
her added responsibility, they are doubly so. In order to get the
best results, exercise or work should so be adjusted as not to reach
the point of fatigue. The mother whose nights are disturbed should
be given the benefit of a midday rest of an hour or two. She
should have at least eight hours' sleep out of every twenty-four.
Certain annoyances, anxieties, and worries are inseparable from the
life of every child-bearing woman. It should be our duty, however,
to explain to the mother and to other members of the family that an
important element in satisfactory nursing is a tranquil mind. Dur-
ing the lactation period she should be spared all tmnecessary care
and petty annoyances.
Regularity in Nursing. — The breast which is emptied at definite
intervals invariably works better than does one which is not, not
only as regards the quantity, but the quality of the milk as well;
so that system in breast-feeding is almost as essential to milk-
production as to its digestion and assimilation.
After it is demonstrated that the nursing is progressing satis-
factorily as proved by the satisfied, thriving child, I begin with one
bottle-feeding daily. The advisability is obvious; in case of illness
of the mother, if she is called away from home, or if, for any reason,
the child cannot have the breast, the feeding is provided for. An-
MATlvRNAL NURSING 67
other advantage is that it gives the mother needed freedom from
restraint. She is thus enabled to have the benefit of a change of
scene. Amusements and recreations which the invariable nursing
period denies her can be indulged in. As a result of this greater
freedom, she is able to supply better milk and to continue nursing
longer than if tied continually to the baby, no matter how fond she
may be of it.
Signs of Successful Nursing. — The child shows a gain of not less
than four ounces weekly. This is the minimum weekly gain which
may safely be allowed. When a nursing baby remains stationary in
weight or makes a gain of but two or three ounces a week, it means
that something is wrong, and it will usually, but not invariably, be
found in the milk-supply. When the baby is nursed at proper
intervals and the supply of milk is ample and of good quality, he is
satisfied at the completion of the nursing. If he is under three
months of age, he falls asleep after ten or twenty minutes at the
breast. Wlien the nursing period again approaches, he becomes
restless and unhappy, crying lustily if the nursing is delayed. When
the breast is offered, he takes it greedily. The stools are yellow
and number from two to three daily. The weekly gain in weight
under such conditions is usually from six to eight ounces.
Signs of Unsuccessful Nursing. — Theoretically, every normal
breast baby should be a thriving, well baby. That such is not the
case, is an unfortunate fact. The standard established for a well
baby is not upheld here. When the supply of milk is scanty the
child remains long at the breast and cries when he is removed. He
shows signs of hunger before the nursing hour arrives. A cause of
failure in breast-feeding, and probably the most frequent cause, is
a scanty milk-supply. The chief nutritional elements in mother's
milk are fat, 3 to 4 percent; sugar, 7 percent; proteid, 1.5 percent.
Failure may be due to a marked disproportion of these elements
which may cause sufficient indigestion and resulting loss in weight
to necessitate a discontinuance of nursing. Thus there may be a
high fat — from 5 to 6 percent; or very low fat — from i to 1.5 per-
cent. In the high-fat cases there will usually be diarrhea with green,
watery stools. The child strains a great deal and there are green
stains on many of the napkins. In high-fat cases there is also regur-
gitation or vomiting of sour material. The fat-globules may readily
be made out if the vomited material is placed under a low-power
microscope. Low fat means deficient nourishment and may cause
constipation. Sugar is rarely a cause of trouble in nursing babies.
It seldom varies, ranging from 5 to 7 percent in the great majority
of breast-milks. Young children, further, have a marked toleration
for it. The proteid of mother's milk is the most frequent cause of
nursing difficulties. Like the fat, it may so be decreased that
nutritional disorder may be induced in the patient, or it may be
68 NUTRITION AND GROWTH
very much increased, the latter being usually the cause of colic or
constipation in otherwise healthy nursing infants. In such infants
curds may be found in the stools, the passage of which is always
accompanied by a great deal of gas. The milk may contain the
normal percentage of fat, sugar, and proteid, but be scanty in
amount. Instead of the four or five ounces to which the child is
entitled, he may get but one or two ounces. Whether or not the
quantity is sufhcient, can be determined by weighing the baby
before and after each nursing for twenty-four hours. One ounce of
breast-milk weighs practically one ounce avoirdupois. The quality
or strength is determined by an examination of the milk itself
(page 76). Before nursing, the child is put in the scales without
undressing him and the weight noted. He is allowed to nurse
fifteen minutes. He is then removed from the breast and weighed.
A child under one week old should gain from i to i^ ounces; at
three weeks of age, i^ to 2 ounces; four to eight weeks of age, 2 to
3 ounces; eight to sixteen weeks of age, 3 to 4 ounces; sixteen to
twenty-four weeks of age, 4 to 6 ounces; six to nine months of age,
6 to 8 ounces ; nine to twelve months of age, 8 to 9 ounces. Of
course, arbitrary limits cannot be fixed as to the quantity.
Stationary weight or loss in weight with a dissatisfied child usually
means defects in quantity which are readily proved by the weighing.
To be fed at the breast may also cause the child to suffer from an
excess of good milk, in which event there will be vomiting or regurgi-
tation, usually associated with colic. When this overfeeding con-
tinues, dilatation of the stomach develops, vomiting becomes
habitual, the child loses in weight, and the breast-milk is said not
to agree, and often, unfortunately, the baby is weaned. This has
been the outcome in scores of cases. When there is habitual vomit-
ing and colic in a nursing baby, two things are to be done — the
baby must be weighed before and after nursing, and the milk must
be examined.
I have repeatedly treated children for indigestion who were
entirely relieved by shortening the nursing period. Weighing the
baby at intervals of from three to five minutes and noting the gain
has shown that the three or four ounces which may be the child's
stomach capacity were obtained in two, three, or five minutes, the
excess which the child took over this amount being the cause of his
trouble. Given a free, full breast and a vigorous nurser, and one
ounce will be taken in one minute. When the nursing "gait" is
established, a child should be kept up to the schedule. There are
few more pernicious teachings than that a baby should be allowed
to nurse when he wants to and as long as he wants to. The idea
that a nursing infant will take no more than is good for him is the
fruit of inexperience. Recently a mother consulted me in regard to
putting her one-month-old baby on the bottle, as he had many green
MATERNAT. NURSING 69
stools, cried a great part of his waking hours, and weighed but a few
ounces more than at birth. Her milk was supposed to be "too
strong" for the child. An examination of the breast and a talk with
the mother satisfied me that the breast-milk was not at fault. An
examination of the milk proved it to be good average milk — 3.5
percent fat, 6 percent sugar, 1.45 percent proteid. A one day's
test by weighing was decided upon. He was allowed to nurse one
minute and rest one minute. During the resting period he was
weighed. Weighing and resting him in this way, it was found that
in three minutes he got from 3 to 3^ ounces of milk. The nursing
was then reduced to three minutes on one breast and five minutes
on the other, which was the "slower" breast of the two. Every
sign of indigestion promptly disappeared after this change. The
stools became normal and the infant made a satisfactory gain in
weight of one ounce daily.
The quantity may be suitable for the age of the child, he may
not vomit or show a sign of indigestion, and yet he may not thrive.
In such a case an examination or repeated examinations of the milk
at intervals of two or three days will usually show that it is poor,
below the normal perhaps in both fat and proteid. Such a case
occurred in the New York Infant Asylum. A Swedish woman was
admitted with an infant two months old in fair condition. She had
an abundance of milk and asked for a foster-child, so great was her
discomfort from the excessive flow of milk. The weekly weighings
of the children soon revealed that there was no growth, and after
a few weeks both children upon examination showed developing
rickets. The milk was then examined and was found deficient — ■
fat 1.2 percent, sugar 5 percent, and proteid 0.73 percent.
Signs of Insufficient Nursing. — The baby remains long at the
breast, perhaps one-half to three-quarters of an hour. When re-
moved, he is restless and uncomfortable. After a short time, in an
hour or less, he is very hungry and demands frequent nursings day
and night.
Management of Abnormal Milk Conditions. — When it is found
that the breast-milk is too strong or too weak, or when the normal
ratios of fat, sugar, and proteid are not maintained, it may be
possible to increase or diminish the milk strength. It may. also be
possible to increase either the fat or the proteid when desirable.
The heavy milk will usually be found in mothers who are robust,
who eat heartily, and who take but little exercise. In such a mother,
the prescribing of a plain diet, allowing red meat but once a day,
discontinuing the malt liquors or wine, — which it will often be found
that she is taking, — and directing that she walk a mile or two a day,
will frequently bring the milk to digestible proportions. In some
cases, however, this will not be successful, and the colic, constipation,
and vomiting continue, even though the quantity obtained at each
70 NUTRITION AND GROWTH
nursing is within normal limits. In some mothers it will be impos-
sible to change the mode of life, except perhaps as to the discon-
tinuance of alcohol. When such conditions prevail, the mother's
milk may be modified by giving from one-half to one ounce of boiled
water or plain barley-water before each nursing. This is a procedure
to which I frequently resort. One teaspoonful of lime-water added
to one ounce of water before each nursing has made the breast-milk
agree when otherwise it would have been impossible. When the
milk is deficient both in fat and proteid, a diet composed largely
of red meat, poultry, fish, rye bread, or whole-wheat bread, oatmeal,
cornmeal, with two or three pints of milk daily, will often be followed
by an increase both in fat and proteid. The use of alcohol in moder-
ate amounts, in the form of malt liquors or wine, will usually increase
the fat. I have frequently seen it advance 2 percent in from two
to three days. Disappointments in improving the quantity or
quality of the breast-milk, however, are frequent.
In addition to the one bottle which, for reasons above mentioned,
is given early in the child's life, I find it necessary at the seventh
month to add an extra bottle or two. Usually at this time the proteid
in human milk begins to diminish in quantity, and as this is the
most important nutritional element, an insufficient quantity at this
rapidly growing period of life is a matter of no little importance.
At the twelfth month, with very few exceptions, my nursing babies
are weaned from necessity. At this age exclusive nursings, if one
considers the best interests of the child, are practically out of the
question. Out of many thousands of mothers I recall but one
instance where a mother was able successfully to nurse her child
after the twelfth month. This remarkable woman, a mother of
six children, had nursed every one of them exclusively up to the
fifteenth or the eighteenth month.
Mixed Feeding. — With a diminution in the amount of milk
secreted, the breast-milk must, of course, be supplemented by
modified cow's milk. This method of feeding is usually successful.
If the mother of a six-months-old baby can satisfactorily nurse him
three times in twenty-four hours, he is given, in addition, three
bottle-feedings, in this way supplementing the mother's milk. It
is best when using mixed feedings to alternate the breast and the
bottle. The modified milk strength should be that which is suitable
for the average child of his age. (See Infant-Feeding, page 81.)
In beginning the use of cow's milk, however, it must be remembered
that at first a weaker strength must be used than the child will re-
quire for growth, this weaker food being necessary in order gradu-
ally to accustom him to the change. If too strong a cow's-milk
mixture is given at first, it will be very apt to disagree, causing
colic and vomiting. Later, when the child has become accustomed
to the new food, a stronger mixture may be given. When a mother
MATERNAL NURSING
71
cannot give her infant at least two satisfactory breast-feedings daily,
it is better to wean the child.
Maternal Conditions under Which Nursing is Forbidden. — When
the mother has tuberculosis in any of its various forms or manifesta-
tions, whether it involves the glands, the joints, or the lungs, breast-
feeding is to be forbidden. In epilepsy and syphilis nursing is
likewise forbidden. In nephritis and malignant disease of any
nature, and in chorea, nursing should be discontinued. Women
who are rapidly losing weight should not be allowed to continue
nursing their infants. In case of serious illness of any nature, such
as typhoid fever, pneumonia, or diphtheria, and upon the advent
of pregnancy, nursing should be stopped.
Care of the Breasts during Weaning. — When the breast-feeding
is carried on the usual length of time, — from nine to twelve months, —
the process of weaning ordinarily causes little or no discomfort. All
that is usually required is to press out enough of the milk to relieve
the patient as often as the breast becomes painful, which may not
be more than two or three times a day. When the weaning is
necessarily abrupt, no little discomfort may result. If there is a
free flow of milk, which is apt to be the case when the weaning must
take place in the early nursing period, tightly bandaging the breasts
is required. When localized hardened areas occur in the glands,
they should be massaged until softened, and the bandage reapplied
and worn until the secretion ceases. When the weaning can more
gradually be done, the best way is to give one less nursing every
second or third day until only two are given. After this has been
practised for one week, these also can be discontinued. In cases
where sudden weaning is required, a saline laxative, such as citrate
of magnesia or Rochelle salts, should be given every day for five
days — sufficient to produce two or three watery evacuations daily.
In the mean time the mother should abstain from fluids of all kinds
up to the point of positive discomfort.
Conditions Which may Temporarily Produce an Unfavorable
Effect upon the Breast-milk, but not Necessitate the Discontinuance
of Nursing. — The advent of the first menstruation period particularly,
and in some cases of every menstruation period, is attended with an
attack of colic or indigestion on the part of the child, rarely sufficient,
however, to necessitate the discontinuance of the nursing even for
a single day.
Factors influencing the mental conditions of the mother, such
as anger, fright, worry, shock, distress, sorrow, or the witnessing of
an accident, may affect the milk secretion sufficiently to cause no
little discomfort to the child, and oftentimes the temporary lessening
of the flow for a day or two. The influence of the mental state upon
the character of the milk was early brought to my attention while
resident physician at the Country Branch of the New York Infant
72
NUTRITION AND GROWTH
Asylum. In this institution there were usually about two hundred
nursing mothers, the majority of them from the lower walks of life,
at least 95 percent of the infants being illegitimate. The necessity
of placing a considerable number of these mothers in wards, and
their living thus in close contact, gave rise to rather frequent disputes,
and not infrequently to fistic encounters of a decidedly vigorous
character. After a particularly active disturbance, several nursing
infants in the ward would be taken suddenly ill, usually with vomit-
ing, diarrhea, and fever. When two or more infants were thus
discovered ill, we soon learned to know the cause when inquiry or
evidence furnished by hasty inspection of the mother showed that
she had been particularly active in the affair. A small proportion
of the mothers were from the better walks of life. Letters of for-
giveness or reproach or visits
of a like nature from fathers,
mothers, or sisters, have
brought many a sick baby
to my attention and caused
me many anxious moments.
Conditions Which call for
Temporary Discontinuance
of Nursing. — During an acute
illness with fever, such as
indigestion, tonsillitis, and
minor illnesses of a like na-
ture, nursing should be dis-
continued for a day or two.
When the infant is removed
from the breast, it should be
our effort to maintain the
flow of the milk. This is
best done by emptying the
breast with a breast-pump (page 79) at the usual nursing period
until the time arrives when the nursing may be resumed. In such
conditions the advantage of having the baby accustomed to one
bottle a day will at once be appreciated.
Care of the Nipples. — Six hours after delivery or confinement
the nipples should be washed with a saturated solution of boric acid
and the child put to the breast and nursing attempted. After this,
the attempts at nursing should be repeated every four hours, although
the milk does not appear in the breasts until from forty-eight to
seventy-two hours after the birth of the child. Colostrum may be
present, which is useful as a laxative and may satisfy the child. A
further advantage of the nursing at this time is that it gradually
accustoms both the nipple and the infant to what will be required
of them later. Immediately after the nursing, the nipple should
Fig. 7.— Nipple-shield.
THE WET-NURSE 73
be carefully washed with a saturated solution of boric acid and
thoroughly but gently dried. A baby should never be allowed to
nurse on a cracked or fissured nipple. For this very painful con-
dition a nipple-shield (Fig. 7) should always be used.
Giving of Water. — From one-half to one ounce of a i percent
solution of milk-sugar should be given the infant every two hours
until the milk appears in the breast. Otherwise there will be unnec-
essary loss in weight and perhaps a high degree of fever due to
inanition.
If the child is restless and uncomfortable, it is safe to conclude
that he is thirsty, and one ounce of the sugar-water will usually
satisfy him. With the commencement of nursing, accustom the
babv to getting his food at regular intervals.
Frequency of Nursings. — The new-born infant is entitled to
ten nursings in twenty-four hours. From 6 a. m. to 10 p. m.,
inclusive, there should be nine nursings. There may be one nursing
at 2 or 3 A. M. As the child becomes older less frequent nursings
are required. The following table will be found useful in this
connection :
3d to the 21st day 10 nursings.
3d " " 6th week 9
6th " " 12th week 8
3d " " 5th month 7 "
5th " " 7th month 6-7
7th" " 12th month 5-6
THE WET-NURSE
We are called upon to select a wet-nurse under various conditions.
In a few families, particularly in those who have had disastrous
feeding experiences, we are asked that no attempts at artificial
feeding be made, but that a wet-nurse be engaged in advance of the
confinement so as to be ready when the time for her serv'ice arrives.
Usually, however, our minds and those of the parents turn to the
wet-nurse when nutrition by other methods is a failure. It is well
to remember in this connection that it is not wise to postpone our
resort to the wet-nurse too long — until every chance for her being
of assistance has passed. It may take a few days' observation or
but a single glance at one of these difficult feeding cases for us to
decide whether a wet-nurse must be secured. Certain it is that in a
few cases we cannot do without them. I see perhaps two or three
cases a year, usually in consultation, in w^hich I insist that further
attempts at artificial feeding be discontinued because of the reduced
condition of the patient.
In the selection of a wet-nurse the age during which nursing is
most successfully carried on is to be- remembered. Other things
being equal, a wet-nurse should not be under twenty-two or over
thirty-five years of age. The peasant women of the continent of
74 NUTRITION AND GROWTH
Europe make the best wet-nurses. A woman should not be selected
as a wet-nurse without a thorough examination both of herself and
of her infant. She must be free from skin diseases, tuberculosis,
and syphilis. Whether she is stout or thin, tall or short, amounts to
little. Neither can we place much reliance on the size of her breasts.
Although full, firm breasts and prominent nipples are desirable, the
best indication as to her nursing ability is the condition of her baby.
For this reason it is best not to select a woman before her baby is
four weeks old, for by that time his physical condition will indicate
with considerable accuracy the kind of food he has been getting.
The age of the wet-nurse's milk need not correspond with the age of
the patient for whom she is engaged. As far as age is concerned, a
breast-milk from four weeks to three months old will answer for any
infant.
The results attending the first few days of wet-nursing are often
most disappointing. The radical change which takes place in the
nurse's habits of life, the leaving of her own child to the care of
others sometimes produces nervous conditions which may have a
decidedly unfavorable influence upon her milk. So before arriving
at the conclusion that she will not answer in a given case, she should
have time to adjust herself to the changed conditions. Many a good
wet-nurse has been ruined, so far as her usefulness as a milk-producer
is concerned, by over-indulgence at the table. She has been accus-
tomed to a very plain diet and some work, which necessarily means
exercise. Upon assuming her new office she is temporarily the
most important member of the household, next to the baby, and
articles of food are supplied to which she is entirely unaccustomed
and of which she eats plentifully. The result is an attack of indiges-
tion with fever, the baby is made ill, and the usefulness of the wet-
nurse in the family ceases. These women usually do best upon a
plain diet of meat, poultry, fish, vegetables, cereals, and milk. If
they are accustomed to taking beer, one bottle daily may be per-
mitted. Coffee may be allowed to the extent of one cup daily, and
of tea not more than two cups should be allowed. Women of this
class are almost invariably neglectful of the bowel function, so that
this must be attended to. One free evacuation should take place
daily. As a rule, the wet-nurse has been accustomed to work and
will be more contented and happy when her time is occupied. Being
out of doors from three to four hours a day is of decided advantage
to every nursing woman. If she possess sufficient intelligence to
take the baby for his outings, she should be allowed to do so. For
the comfort of the family it is wise not to let a wet-nurse know her
full value. When she feels that she is indispensable, trouble is apt
to follow from one source or another. It is particularly necessary,
therefore, that babies that are wet-nur§ed should be given one
bottle-feeding daily as soon as they are able to take care of it. The
HUMAN MILK 75
wet-nurse will then realize that she can be dispensed with in case of
misconduct, or if she leaves with an hour's notice the child can be
given the bottle until another nurse is secured. In the great majority
of my cases it has not been necessary to continue the wet-nursing
after the children are seven months of age, for by this time they can
usually be fed on the bottle. Of course, unless her nursing proves
unsatisfactory, a wet-nurse should not be dismissed at the com-
mencement of or during the summer.
HUMAN MILK
While human milk varies as to the proportion of its nutritional
elements at different periods of lactation, and even at different
times of the day, milks upon which infants thrive agree within cer-
tain limits, so that a standard of limitations may be laid down.
Among a great many specimens which I have examined the solids
have ranged between 12 and 13 percent. The range in fat has been
from 2.75 to 4.65 percent, proteid from 0.9 to 1.8 percent, sugar
from 5.50 to 7.3 percent. These figures represent the analyses of
the breast-milks given children who were thriving and who were of
different ages. These variations are not as wide as have been
reported by others, but it is to be remembered that these were all
babies who were thriving. Whoever has examined breast-milk
even a few times is aware of the existence of the widest possible
variations. I have seen breast-milks which contained 8 percent
of fat and others which contained only 0.5 percent, but children
thus fed were not well. Fat exists in mother's milk in minute glob-
ules as an emulsion. It varies somewhat in composition, depending
upon the kind of food eaten.
The proteids of breast-milk offer a wide field for further study.
There are several of these proteids, the most important being casein
and lactalbumin. The proportions are subject to considerable
variation, depending upon the diet and habits of life of the producer.
With a continuation of lactation there is a diminution of the pro-
teid, so that at the ninth or tenth month it is considerably reduced,
the total proteid often being not over i percent. The sugar content
varies less than does either the fat or proteid, its range of limitation,
even in milk otherwise poor, being not over 1.5 or 2 percent.
Directions for nursing well children will be found on page
62. As to whether the child is getting a sufficient quantity
of milk may be determined by weighing the baby before and after
nursing. For this purpose the scales used for weighing children
should weigh accurately in one-half ounces. The child need not be
undressed. He is weighed when put to the breast and weighed at
the completion of the nursing. I have repeatedly found children
who should get three ounces or more at a feeding who after the
76
NUTRITION AND GROWTH
fifteen-minute nursings had increased in weight but one-half or one
ounce, showing that only so much milk had been taken. Occasion-
ally cases have been seen where there was no gain whatever after
nursing and yet the child was supposed to have been fed. In
difficult breast-feeding it is well personally to supervise a nursing
or two, by which means much valuable information may be gained.
Examination of Human Milk. — Milk of the mother is usually
examined to determine whether it contains a sufficient amount of
fat, sugar, and proteid to nourish the infant ; or to determine whether
the quantity of one or more of
the nutritional factors is exces-
sive or deficient. Microscopic
examination shows us little ex-
cept the presence of colostrum,
which usually disappears about
the ninth day and is to be con-
sidered abnormal if present
after the twelfth day. The
presence of blood and pus may
also be detected by the micro-
scope. For an accurate analy-
sis the milk should be sent to
a laboratory properly equipped
for such work. For absolute
accuracy it is not safe to judge
from the analysis of one speci-
men of milk; at least two,
better three, specimens should
be analyzed before coming to a
conclusion. In collecting milk
for examination the middle of
a nursing should be selected.
Laboratory analysis is ex-
pensive, however, and beyond
the possibilities of many. For
out-patient work and those cases
in which a determination of ap-
proximate percentages is sufficient I have found the Holt milk set
(Fig. 8) of great service. The set consists of a lactometer and
two cream-gages. The method of its use is explained by Holt as
follows :
"The simplest method is by the cream-gage. Although its
results are only approximate, they are in most cases sufficiently
accurate for clinical purposes. The tube is filled to the zero mark
with freshly drawn milk, which stands at room-temperature for
twenty-four hours, when the percentage of cream is read off. The
Fig. 8. -The Holt Milk Set.
CRACKED AND FISSURED NIPPLES
77
ratio of this to the fat is approximately five to three ; thus 5 percent
cream indicates 3 percent fat, etc.
"Sugar. — The proportion of sugar is so nearly constant that
it may be ignored in clinical examinations.
" Proteids. — We have no simple method for determining clinically
the amount of proteids. If we regard the sugar and salts as con-
stant, or so nearly so as not to affect the specific gravity, we may
form an approximate idea of the proteids from a knowledge of the
specific gravity and the percentage of fat. We may thus determine
whether they are greatly in excess or very low, which, after all, is
the important thing. The specific gravity will then vary directly
with the proportion of proteids, and inversely with the proportion
of fat — i. e., high proteids, high specific gravity; high fat, low specific
gravity. The application of this principle will be seen by reference
to the accompanying table. ^
"WOMAN'S MILK
Specific Gravity, 70° F.
Cream— 24 Hours.
Proteid (Calculated).
Average
Normal varia-
tions. .
1.031
1.028-1.029
1.032
Low (below 1.028)
Low (below 1.028)
High (above 1.032)
High (above 1.032)
7 percent.
8 percent- 12
percent.
5 percent-6
percent.
High (above 10
percent).
Low (below 5
percent) .
High.
Low.
1.5 percent.
Normal (rich milk).
Normal (fair milk).
Normal (or sHghtly be-
low).
Very low (very poor
milk).
Very high (very rich
milk).
Normal (or nearly so).
Normal varia-
Abnormal varia-
tions
Abnormal varia-
Abnormal varia-
tions
Abnormal varia-
tions
"Any specimen taken for examination should be either the
middle portion of the milk — i. e. , after nursing two or three minutes —
or, better, the entire quantity from one breast, since the composition
of the milk will differ very much according to the time when it is
drawn. The first milk is slightly richer in proteids and much poorer
in fat."
CRACKED AND FISSURED NIPPLES
Fissures of the nipples are often the result of lack of care
and cleanliness. Nipples that are not washed and dried, but
allowed to remain moist after nursing, particularly during the
first few days, are also very apt to become macerated and cracked.
In the cases in which there is a tendency for the breasts to "leak," the
milk decomposes on the nipples, and in addition to the maceration,
^The Holt apparatus may be obtained from Eimer & Amend, Eighteenth
Street and Third Avenue, New York.
78 NUTRITION AND GROWTH
the nipple is excoriated by the acids formed by the decomposition
in the milk. Leaking nipples should be kept covered with pads of
sterile absorbent gauze. Cracks and fissures in the nipple may be
sufficiently painful to prevent a continuance of the nursing. In
getting the histories of not a few bottle babies, I have been told
that nursing had been stopped because of cracked nipples. The
prevention and successful treatment of the condition, therefore, is
a matter of no little importance. A strong child tugging on a
fissured nipple may be an excruciatingly painful process for the
mother, and when the fissures are not healed, it can readily be
understood that the pain accompanying and the dread of nursing
may produce sufficient mental distress to change the character or
stop the flow of the milk, either of which may require that the
nursing be discontinued.
Treatment. — The treatment which gives the best results, and
which is used exclusively at the New York Infant Asylum and
Maternity, is to bathe the parts with a saturated solution of
boric acid after each nursing, dry the nipple, and apply a pad
of sterile gauze. Once or twice a day, the cracks or fissures are
painted with an 8 percent solution of nitrate of silver. There is no
pain attending this application. The pad of sterile gauze just
referred to is placed over the nipple and held in position by a binder
sufficiently tight to support the breasts. Before the next nursing
the nipple is bathed with sterile water and the infant takes the
breast as usual. If there are deep fissures, it may be well for a day
or two to use a nipple- shield. Another important reason for a rapid
healing, is the danger of infecting the gland through the open nipple
wound — the usual cause of mammary abscess. The use of an
ointment to the nipples is not advised, for the reason that it is of
little or no service; in fact, in most cases ointments do harm because
they soften the epithelium and make the nipple tender.
CAKING OF THE BREASTS
Caking of the breasts is very apt to occur during the first few
days of nursing. The milk, when it appears in the breasts, is often
secreted in large amount. A great deal more is supplied than the
child, with its small stomach and usually indifferent nursing, is able
to digest. The breasts should be watched very carefully during
this time so as to guard against the possibility of the milk remaining
undrawn, with the resulting harm. After the completion of the
regular nursing, if a considerable amount of milk remains in the
breasts, it should be drawn by the breast-pump (Fig. 9) and the
breast thus relieved.
Treatment. — When nodules form, they may readily be soft-
ened by gentle massage. Lanolin should be used on the fingers
so as to avoid unnecessary irritation of the skin. The massage
ACUTE AND SUPPURATIVE MASTITIS IN THE MOTHER 79
should be repeated as often as the nodules appear. The caking is
more apt to occur in the dependent portion of the glands. The
so-called pendulous breasts, which may show a tendency to cake,
should be supported by a binder lightly applied.
DEPRESSED NIPPLES
Not an infrequent source of difficulty in the management of the
nursing function in a primipara is depressed nipples. The child
cannot get a sufficient hold to make suction possible. He thus
fails to get the desired nutriment, and both the child and the mother
become exhausted in consequence. When this is repeated a few
times, the child is very apt to refuse to make any attempt at nursing.
In such cases the use of the nipple-shield (Fig. 7) is often indispens-
able, until the nipple is sufficiently drawn out and developed for
the child to get hold of. Preceding each nursing it is well to man-
ipulate the nipple for a few minutes or to elongate it by the use of
i-
^ii
I'
Fig. 9.— English Breast-pump.
the breast-pump (Fig. 9), but not using sufficient force to draw the
milk.
ACUTE AND SUPPURATIVE MASTITIS IN THE MOTHER
When inflammation of the breast develops with fever, chills, and
prostration, it is usually the result of an infection through the nipple,
generally one with visible cracks and fissures. The nursing of the
involved breast should be discontinued, for the sake of both the
child and the mother; in fact, the pain is often so great that nurs-
ing is impossible. A supporting bandage should be applied and
the milk drawn with the breast-pump at the usual nursing times.
It must be our aim to induce resolution without the formation
of pus. This is best accomplished by the use of an ice-bag
which is kept constantly applied to the inflamed, indurated area.
If there is a tendency to constipation, saline laxatives should be
used. With a subsidence of the temperature and an abatement of
the inflammation, nursing may be resumed. As soon as the presence
8o NUTRITION AND GROWTH
of pus is determined, it should be removed regardless of its location
in the gland. I have seen cases of intestinal infection in the infant
and of infectious processes in other parts of the body that were
undoubtedly due to its being allowed to nurse on suppurating breasts.
SUBSTITUTE BREAST-FEEDING; ARTIFICIAL FEEDING
A considerable number of the young of the human race are
deprived of their natural means of nutrition, the milk of the mother.
For comparatively few is a wet-nurse available. While in proportion
to the children born more mothers are nursing their infants now than
formerly, nevertheless every year thousands of infants are brought
into the world who have to be nourished by other means than human
milk. The fact that an immense number of deaths occur every
year among these infants because of defective nutrition speaks for
itself.
Nutritional Errors. — Mortality statistics give a very inadequate
idea as to the part played by nutritional errors in the young, for the
reason that in many instances such errors are not the direct or perhaps
the immediate cause of death, and for this reason their influence does
not appear in mortality statistics. As elsewhere pointed out, and
dwelt upon at length in this work, in disease of any nature a child's
resistance is a factor of paramount importance. With defective
nutrition, resistance is invariably below the normal. Many of the
infants who die from the intestinal diseases of summer, from grippe,
from tuberculosis, or from infectious diseases, suffer from defective
nutrition in different degrees of severity before the immediate cause
of death appears.
The Needs of the Patient Paramount. — As the nutrition deals
directly with questions of life and death, it is not surprising that
volumes have been written on the subject, but it is surprising that the
fundamental principles of infants' nutrition are so little tmderstood.
This is due in part to the fact that writers and teachers of infant- feed-
ing, in their efforts to be scientific or ultra-scientific, have lost sight
of the point that there is a patient as well as a pupil to be considered,
and that not a few teachers with their algebraic or otherwise intricate
formulas do little but obstruct the progress of rational feeding by
making a readily comprehended subject impossible to many. Another
common error is in not distinguishing between children — the rich
and the poor, the sick and the well. A child with malnutrition, with
marasmus, or with a temporarily disordered digestion is by no means
a well baby, and when he is given food suitable only for the well, his
condition very naturally is not improved.
Environment. — In feeding an infant, several predominant factors
must be considered : First, the influences of environment. The infant
in a children's institution has to be fed differently from one who comes
to a dispensary for treatment, and both must be fed differently in
SUBSTITUTE BREAST-FEEDING ; ARTIFICIAL FEEDING 8 1
summer than in winter. The child of well-to-do, intelligent parents
is fed still differently. There are no hard and fast lines in infant-
feeding other than that there must be an ample supply of such
nourishment as the child can digest and thrive upon. Cow's milk
is used as the basis of infants' feeding for the reason that it is
ordinarily readily adapted to the child's digestion and is the most
available human milk substitute.
Successful Substitute Feeding. — Successful substitute feeding of
infants consists, then, in giving something upon which the child can
live and thrive, and when, in addition, this "something" supplies
the nutrition which Nature demands, it constitutes scientific infant-
feeding, whatever the source of the nutriment. Cow's milk is just
as fully an unnatural food for an infant as is barley or rice gruel or
the milk of the goat or the ass, and cow's milk only is used, as already
mentioned, because in a great majority of cases it answers the given
purpose better than does any other food, in that it furnishes in
available form the nearest approach to the nutritional elements
required. From an analysis of many human milks we know what
should constitute a child's food. Cow's milk, however, differs from
human milk in important features (page 98).
Modified Milk. — The changing of cow's milk through manipu-
lation so that it may conform more closely to human milk, and
consequently be more acceptable to the digestive capacity of the
child, has given rise to the term "modified milk," which is the
result of a mechanical procedure. The term is a very elastic one,
and means simply that the milk is so changed that the relative
proportions of the nutritional elements correspond more nearly
to those of human milk. There are other differences, however,
between cow's milk and human milk than the simple matter of
the proportion of their ingredients. The principal difference is
in the character of its casein. The making of the casein of cow's
milk to simulate human-milk casein constitutes practically what I
liave termed "milk adaptation," and will be considered under that
heading.
When cow's milk is diluted with water and given as a food to
an infant he is given "modified milk." When sugar or lime-water
or a cereal gruel is added, it is still modified milk. When a pre-
scription is sent to the laboratory calling for definite amounts of
fat, sugar, and proteid, the product furnished is modified milk.
When a mother is told to use a definite amount of cream, milk-sugar,
and water, modified milk is the outcome.
The analysis of mixed dairy milk shows it to contain approxi-
mately :
4.0 percent fat;
4.0 percent sugar ;
3.5 percent total proteid.
6
82 NUTRITION AND GROWTH
Human milk contains approximately :
4.0 percent fat ;
7.0 percent sugar;
1.5 percent total proteid.
The Aim of Milk Modification. — The first thought in the modi-
fication is grossly to make the chief nutritional elements in the food
prepared from cow's milk correspond to the nutritional elements in
the human milk. The proteid must be reduced, the sugar increased,
and the fat reduced even slightly below that usually found in mother's
milk, as the child's digestive capacity for cow"s-milk fat is less by
from 15 to 25 percent than it is for human milk.
The Proteid. — The proteid element in an infant's food is its chief
nutritional content. This has to be reduced to approximately the
proportions that exist in human milk, and can be accomplished only
by dilution. The diluent may be plain water or it may be a cereal
gruel. The average cow's milk contains, as just mentioned:
4.0 percent fat;
4.0 percent sugar ;
3.5 percent total proteid.
If eight ounces of milk is mixed with eight ounces of water, we get
a pint mixture with an approximate nutritional equivalent of :
2.0 percent fat;
2.0 percent sugar;
1.75 percent total proteid.
If four ounces of milk is mixed with twelve ounces of water we have
a sixteen-ounce mixture with an approximate nutritional equivalent
of:
i.o percent fat;
i.o percent sugar;
0.9 percent total proteid.
If six ounces of milk is mixed with ten ounces of water a sixteen-
ounce mixture is produced with an approximate nutritional equiva-
lent of:
1.5 percent fat;
1.5 percent sugar;
1.3 percent total proteid.
By this simple dilution with water it may be seen that the desired
proteid content of the food may be arrived at.
The Sugar. — For nourishment for an infant, however, the mixture
is weak in fat and very weak in sugar. The sugar content is increased
by the addition of milk-sugar or cane-sugar. It will be remembered
substitute; breast-feeding; artificial feeding
83
that with human milk there is a sugar content of 7 percent. The
combination of full cow's milk and water as above gives a sugar
content of 2 percent or less, so that sufficient sugar must be added
to make the increase approximately 7 percent. What is necessary,
then, is to increase the sugar content 5 percent. A i percent sugar
and water mixture would contain approximately five grains of sugar
to the ounce. A 6 percent sugar mixture would contain thirty
grains to the ounce, and as our dealings are with
a sixteen-ounce mixture we will require an addi-
tion of sixteen times thirty grains of sugar of milk,
or 480 grains, so that if we direct that a pint mix-
ture contain 6 ounces of a 4, 4, 3.50 milk, 10 ounces
water, i ounce milk-sugar, there would be an ap-
proximate nutritional equivalent of :
1.5 percent fat;
7.5 percent sugar;
1.3 percent total proteid.
Or if it were 4 ounces milk, 12 ounces water, i
ounce milk-sugar, there would be a nutritional
equivalent of;
1 .0 percent fat ;
7.0 percent sugar;
0.9 percent total proteid.
The Fat. — While a child of from two to four
months might thrive on the above formulas, the
fat is obviously deficient and needs to be increased.
This is accomplished by the use of cream.
Cream of the same age as the milk should be
used. When this method of feeding is carried
out, in order to secure a suitable cream, a quart
bottle of milk from a mixed herd of grade cows
is allowed to stand at a temperature of 40° or
50° F. for five hours, when a cream will be pro-
duced of the approximate strength of :
16.0 percent butter fat;
3.2 percent sugar;
3.2 percent total proteid.
Cream from well-fed Jersey cows procured in this
way will contain from 20 to 24 percent of fat.
These were the percentages obtained in an analysis made for me
from the Walker-Gordon Laboratory milk, which is produced by
grade cows and represents an average milk strength as regards the
nutritional elements, and may therefore be taken as a guide in using
gravity cream for infant-feeding. One ounce of gravity cream with
Fig. 10.— The Chapin-
Dipper.
84 NUTRITION AND GROWTH
fifteen ounces of water gives a pint mixture with a nutritional
equivalent of:
I .o percent fat ;
0.2 percent sugar;
0.2 percent total proteid.
Two ounces of gravity cream and fourteen ounces of water give an
approximate nutritional equivalent of :
2.0 percent fat;
0.4 percent sugar;
0.4 percent total proteid.
We now wish by using gravity cream to raise the fat in the milk
and sugar-water mixtures given above. In using the cream all
must be removed and mixed, as the upper layers are much richer
in fat than those nearer the milk. For this skimming process the
Chapin dipper (Fig. 10) is employed. Milk which is rapidly cooled
immediately after being drawn and kept at a temperature of 50° F.
or lower ma}' be skimmed at the end of five hours, when all the
cream that will rise will have done so.
Illustrative Food Formulas.
Gravity cream 1 ounce Approximate Percentage Equivalent.
Milk 4 ounces Fat 2.0
Milk-sugar 1 ounce Sugar 7.2
Water II ounces Total proteid 1.1
Gravity cream 2 ounces Approximate Percentage Equivalent.
Milk 4 ounces Fat 3.0
Milk-sugar 1 ounce Sugar 7.4
Water 10 ounces Total proteid 1.3
In the event of a weak proteid digestion in a young baby, gravity
cream alone may be used temporarily ; thus 3 ounces cream, i ounce
milk-sugar, 12 ounces water, i ounce lime-water, which mixture
gives an approximate nutritional equivalent of:
3.0 percent fat;
6.6 percent sugar;
0.6 percent total proteid.
Or if a weaker food is desired for a younger infant, we may use
2 ounces gravity cream, i ounce milk-sugar, 13^ ounces water,
^ ounce lime-water, which mixture gives an approximate equiva-
lent of:
2.0 percent fat;
6.4 percent sugar;
0.4 percent total proteid.
In the event of a good proteid digestion and poor fat digestion, full
milk alone with sugar and water is to be used ; thus 5^ ounces milk,
SUBSTITUTE breast-feeding; ARTIFICIAL FEEDING 85
TO ounces water, i ounce milk-sugar, 1 5 ounces lime-water, which
mixture gives an approximate equivalent of:
1.33 percent fat;
7.33 percent sugar;
1 . 1 7 percent total proteid.
Average skimmed milk with the gravity cream removed contains
about I percent fat, 3.5 percent sugar, and 3 percent proteid. If
for any reason a particularly weak fat food is required, skimmed
milk may be used: 5-3 ounces skimmed milk, 9 ounces water, i ounce
milk-sugar, if ounces lime-water, which mixture gives an approxi-
mate equivalent of :
0.30 percent fat;
7.15 percent sugar;
1 .00 percent total proteid.
If a stronger skimmed milk mixture is required, it may be pre-
pared as follows: 8 ounces skimmed milk, 8 ounces water, i ounce
milk-sugar, which mixture gives an approximate nutritional equiva-
lent of:
0.50 percent fat;
7.75 percent sugar;
1.50 percent total proteid.
It will thus be seen that with milk, cream, and sugar of milk every
possible form of food strength may be made. If lime-water is used,
it simply takes the place of the milk diluent and replaces so much
water. This method of milk preparation is more accurate than
when top-milk mixtures are used, but it has the disadvantage of
requiring two quarts of milk during the entire feeding period, one
to supply the milk and the other the cream, all of which must be
removed and mixed before any of it is used in the food.
The following formulas for the different ages may be found
useful for well babies:
From the first to the third day:
Milk-sugar J ounce
Boiled water 16 ounces
I to 1 ounce every two or three hours;
which mixture gives an approximate nutritional equivalent of
3 percent sugar.
From the third to the tenth day:
Gravity cream h ounce Approximate Percentage Equivalent.
Milk 3" ounces Fat 1.25
Milk-sugar 1 ounce Sugar 6.7
Lime-water h ounce Total proteid 0.66
Boiled water to make 16 ounces
Ten feedings in twenty-four hours ; 1 to H ounces at each feeding.
86 NUTRITION AND GROWTH
From the tenth to the twenty-first day:
Gravity cream l;f ounces Approximate Percentage Equivalent.
Milk 5 ounces Fat 1.66
Milk-sugar 1 J ounces Sugar 6.8
Lime-water h ounce Total proteid 0.74
Water to make 24 ounces
Ten feedings in twenty-four hours ; 1 ^ to 2 ounces at each feeding.
From the third to the sixth week:
Gravity cream 2^ ounces Approximate Percentage Equivalent.
Milk 8 ounces Fat 2.25
Milk-sugar 2 ounces Sugar 7.0
Lime-water 2 ounces Total proteid 0.9
Water to make 32 ounces
Nine feedings in twenty-four hours ; 2 to 3 ounces at each feeding.
From the sixth week to the third month:
Gravity cream 3 ounces Approximate Percentage Equivalent.
Milk 9 ounces Fat 2.6
Milk-sugar 2 ounces Sugar 7.1
Lime-water 2h ounces Total proteid 1.0
Water to make '. 32 ounces
Eight feedings in twenty-four hours; 2 J to 4 ounces at each feeding.
From the third to the fifth month:
Gravity cream 4 ounces Approximate Percentage Equivalent.
Milk 15 ounces Fat 3.1
Milk-sugar 2^ ounces Sugar 7.5
Lime-water 4 ounces Total proteid 1.3
Water to make 40 ounces
Eight feedings in twenty-four hours ; 4 to 5 ounces at each feeding.
From the fifth to the seventh month:
Gravity cream 5 ounces Approximate Percentage Equivalent.
Milk 18 ounces Fat 3.6
Milk-sugar 2| ounces Sugar 7.6
Lime-water 5 ounces Total proteid 1.5
Water to make 42 ounces
Six to seven feedings in twenty-four hours ; 5 to 7 ounces at each feeding.
After the fifth month it is my custom to add from one to three tea-
spoonfuls of a cereal jelly to each feeding. This may be added to the
milk mixture when it is made in the morning. Thus, if one teaspoon-
ful is to be given at each feeding v^here a child is getting six feedings,
six teaspoonfuls of the jelly may be added to the entire quantity.
From the seventh to the ninth month:
Gravity cream 6 ounces Approximate Percentage Equivalent.
Milk 23 ounces Fat 3.9
Milk-sugar 2^ ounces Sugar 7.1
Lime-water 6 ounces Total proteid 1.7
Water to make 48 ounces
Five to six feedings in twenty-four hours ; 6 to 8 ounces at each feeding.
SUBSTITUTE BREAST-FEEDING; ARTIFICIAL FEEDING 87
From the ninth to the twelfth -month:
Gravity cream 7 ounces Approximate Percentage Equivalent.
Milk 32 ounces Fat 4.28
Lime-water 6 ounces Sugar 7.6
Milk-sugar 3 ounces Total proteid 2.0
Water to make 56 ounces
Five to six feedings in twenty-four hours ; 7 to 9 ounces at each feeding.
Top -milk Feeding. — In using top milks for infant- feeding the
milk is allowed to stand in a quart bottle at a temperature of 45° to
50° F. for the same length of time as when gravity cream is desired —
five hours — when the quantity needed is removed from the top of
the bottle with a Chapin dipper (Fig. 10) and diluted as desired
with water or gruel to which sugar of milk and lime-water are
added. The milk selected should be the cleanest obtainable from
grade cows; usually the most expensive is the best. If so-called
"certified milk" (page 103) is obtainable, it should be used, as this
warrants a cleaner food than that furnished by the usual market
milks.
From a quart bottle of milk in which the cream has risen, dip
off from the top with a Chapin dipper sixteen ounces and mix. From
average milk this should contain:
7.0 percent fat;
3.2 percent sugar;
3.2 percent total proteid.
The following formulas are suggested for the various ages noted :
From the third to the tenth day:
Top milk 3 ounces Approximate Percentage Equivalent.
Lime-water 2 ounce Fat 1.3
Milk-sugar 1 ounce Sugar 6.6
Boiled water to make 16 ounces Total proteid 0.6
Ten feedings in twenty-four hours; 1 to H ounces at each feeding.
From the tenth to the twenty-first day:
Top milk 6 ounces Approximate Percentage Equivalent.
Lime-water H ounces Fat 1-7
Milk-sugar U ounces Sugar 6.8
Water to make 24 ounces Total proteid 0.8
Ten feedings in twenty-four hours ; 1 J to 2 ounces at each feeding.
From the third to the sixth week:
Top milk 10 ounces Approximate Percentage Equivalent.
Lime-water 2^ ounces Fat 2.2
Milk-sugar 2 ounces Sugar 7.0
Water to make 32 ounces Total proteid 1-0
Nine feedings in twenty-four hours ; 2 to 3 ounces at each feeding.
From the sixth week to the third month:
Too milk 12 ounces Approximate Percentage Equivalent.
Milk-sugar 2 ounces Fat 2.6
Lime-water 3 ounces Sugar 7.2
Water to make 32 ounces Total proteid 1.2
Eight feedings in twenty-four hours; 2 J to 4 ounces at each feedmg.
88 NUTRITION AND GROWTH
From the third to the fifth month:
Top milk 18 ounces Approximate Percentage Equivalent.
Milk-sugar 2h ounces Fat 3.1
Lime-water 4 ounces Sugar 7.4
Water to make 40 ounces Total proteid 1.4
Eight feedings in twenty-four hours; 4 to 5 ounces at each feeding.
From the fifth to the seventh month:
After this age two bottles of milk are required, i6 ounces being
taken from the top of two bottles and mixed :
Top milk 21 ounces .\pproximate Percentage Equivalent.
Milk-sugar 2^ ounces Fat 3.50
Lime-water 5 ounces Sugar 7.5
Water to make 42 ounces Total proteid 1.6
Six to seven feedings in twenty-four hours ; 5 to 7 ounces at each feeding.
From the seventh to the ninth month:
Top milk 27 ounces Approximate Percentage Equivalent.
Milk-sugar 2 J ounces Fat 3.93
Lime-w'ater 6 ounces Sugar 7
Water to make 48 ounces Total proteid 1.8
Five to six feedings in twenty-four hours ; 6 to 8 ounces at each feeding.
From the ninth to the twelfth vwnth:
Top milk 35 ounces Approximate Percentage Equivalent.
Milk-sugar 3 ounces Fat 4.3
Lime-water 6 ounces Sugar 7.3
Water to make 56 ounces Total proteid 2.0
Five to six feedings in twenty-four hours ; 7 to 9 ounces at each feeding.
After the twelfth month, plain cow's milk may be given with the
cereal jelly in addition to the other articles of diet suggested for
a child one year old. (See page 128.)
It will be noticed that considerable latitude is allowed as to
the amount of food which may be given at each feeding. This is
because of the difference in the capacity of individual children.
Night Feedings. — After the third month the midnight feeding
should be discontinued. Seven feedings will be sufficient, the first
at 6 A. M. and the last at 10.30 or 11 p. m.
Between 11 p. m. and 6 a. m. the child should sleep. Babies
are easily broken from the night bottle by substituting a bottle of
boiled water or a milk mixture greatly diluted wdth water. The
child soon discovers that this is not worth waking for. As a restilt
of a full night's rest the digestive organs are better able to do their
work, the appetite is increased, and a larger amount of food may be
given at each feeding.
Changes Needed for Special Symptoms. — When the milk does
not agree, the cause must be discovered. The food as a whole
may be too strong, when there will be indigestion and colic, and
possibly diarrhea and vomiting. If the food contains too much fat,
SUBSTITUTE BRKAST-FEEDING; ARTIFICIAL FEEDING 89
there will be loosoiess of the bowels and colicky stools, with con-
siderable straining, and there is apt to be regurgitation also. The
sugar is rarely a cause of trouble, indications of excess being the
eructation of gas and a regurgitation of sour, watery material. It is
comparatively rare, however, for the fat and sugar to cause any
disturbance if they are given with any degree of intelligence ; but
the casein, the curd-forming element in cow's milk, often gives us
no end of trouble. Many infants, as previously stated, are able to
digest only a very weak cow's-milk casein; consequently, at the
beginning of cow's-milk feeding, when, as is often the case, too
much milk is used — too strong a food given — the result is always
disastrous. This, with too frequent feedings and night feedings,
comprise the chief errors made in cow's-milk feeding — in fact, they
are the cause of more bottle-feeding failures than all other factors
combined.
The Quality of Milk Variable. — It is not claimed that the nutri-
tional value as indicated by the percentage equivalents in either of
the above series is absolutely correct. Milks necessarily differ in com-
position. Only mixed dairy milk is referred to, the product of several
grade cows. The feeding of the cows and their care also influence the
quality of the milk. The percentages indicated give approximately
the nutritional value and are sufficiently accurate for purposes of
supplying satisfactory nutrition to well babies of the various ages, as I
have abundantly proved to my own satisfaction. The fats will not be
found too low for proper nutrition in any of the formulas given.
They may be too high for proper digestion and require adjustment.
The proteids as given are sufficient for nutrition if they are assimi-
lated. They also may require reduction to meet special conditions
which are referred to under Milk Adaptation (page 94). The adjust-
ment of the food to the individual, constitutes what I have termed
"Milk Adaptation," and suggestions for making the food fit the
child's digestive capacity will be found under that caption.
Laboratory Feeding. — To Rotch, of Boston, we are indebted for
the establishment of the practice of thinking in percentages in the
feeding of infants and for the establishment of milk laboratories
which mark an epoch in the feeding of infants. Haphazard methods
of feeding have been superseded by methods which rest upon a
scientific basis. The change for the better has been slow but effec-
tual, so that all who now teach or practise pediatrics successfully
must think in percentages and feed accordingly. The advantages
of using the milk of a properly conducted laboratory are accuracy
in the nutritional content in the food furnished and cleanliness.
It also lightens the household duties, the milk being delivered every
morning ready for use. The physician sends the prescription to the
laboratory on such a prescription blank as that shown on page 90.
90
NUTRITION AND GROWTH
Fat
Milk-sugar
Proteids . .
Lime-water
Diluent . . .
Number of
feedings
Amount of
each feeding
In Qt. Jar-
Heat to
Ordered for-
Date
Signature
-M.D.
The milk thus is dehvered in quart bottles or in as many nursing
bottles as there are feedings in twenty-four hours, each bottle con-
taining the number of ounces called for.
A further advantage possessed by the laboratory is that in very
difficult cases of proteid feeding a finer adjustment is possible than
is the case with home-made preparations, a very valuable aid in the
feeding of such cases. A splitting up of the proteid by using whey
proteid is here more accurately accomplished than is possible in the
home. Unfortunately, the product of milk laboratories, on account
of the expense of equipment and maintenance, together with the
expense of producing a high-grade milk at the farm, is rendered so
expensive to the consumer that it is available to comparatively few.
A Convenient Means for Home Modification. — A measuring
glass has recently been placed on the market, known as the
Deming percentage milk modifier (Fig. ii). The device is a pint
graduate provided with a column of figures in red representing
percentages of proteid, and several other columns representing
percentages of fat. The fat percentages in one column are to
be obtained by using whole milk, in another 7 percent milk, in
another 10 percent, etc. At the head of each column are direc-
tions showing how such a milk may be obtained from a quart bottle
of milk. The figures representing proteid percentages are so placed
on the glass that when milk is poured into the graduate up to the
level of any set of figures and diluent added up to the sixteen-ounce
mark, the resulting mixture will contain a percentage of proteid
corresponding to the red figure at the first level and a percentage
of fat corresponding to the figures at that level in the column which
represents the kind of milk used. For example, if whole milk is
poured in up to the red (proteid) mark 2 and diluent added to sixteen
SUBSTITUTE breast-feeding; artikiciae feeding
91
■ounces, the fat percentage will be 2.5, which is the figure at the same
level as the proteid percentage, and under the whole-milk column.
Or if 7 percent milk is used, 4.4 percent, and if 10 percent, 6.2 per-
cent, etc.
The Feeding of Dispensary Patients. — The feeding of cow's
milk according to one or more of the above methods is the
best means of furnishing infant nutrition. The laboratory, the
milk and cream, or the top-milk methods all pediatrists are
agreed have proved the best means of applying substitute feed-
ing. That a great majority of infants may be fed in this way,
if they are properly handled by a suitable adjustment, there is not
the slightest doubt, but where there is a majority, there is also a
minority, and a goodly portion of
this minority who reside in large
cities and the suburbs of large cities
fall into the hands of the pediatrist
either in hospital, in out-patient, or
in private w^ork. Economic ques-
tions oftentimes govern the selec-
tion of the food. Physicians who
Tiave an invariable system of feed-
ing must of necessity have but one
type of patients to deal with.
As loud as we may be in our
advocacy of the ennobling principles
of democracy, we cannot treat alike,
as regards their feeding, all well chil-
dren even in private practice. The
•child of a stupid mother cannot be
fed as well or in the same way as
the child of a reasonably intelligent
mother in the same station of life.
An infant of a very poor mother,
whether she is dull or intelligent,
cannot be fed to the infant's best advantage, for the reason — a very
simple but effectual one — that the mother cannot afford cow's milk
Among the out-patient class in New York city, the expensive milk
is therefore entirely out of the question. I have treated many infants
whose parents could not expend eight cents daily for a quart of milk.
The Patient's Limitations and How to Meet Them.— The Straus
laboratories, which supply pasteurized milk to the poor of New
York city, excellent as they are, are available to comparatively
few. Milk and cream combinations are impossible oftentimes be-
cause of expense or because of inability to appreciate and carry
out the details required for their proper use, so that in the out-
patient poor class we have to feed either by top-milk methods or
Fig. II.— Deming's Milk Modifier.
92 NUTRITION AND GROWTH
by the simple dilution of full milk with water and sugar or with a
cereal gruel and sugar, while for the very poor, those who cannot
afford cow's milk and ice, we are forced to use condensed milk.
The top-milk method is available to but comparatively few of
these mothers, even though the directions are carefully explained
and printed instructions used. The use of top milks with many,
while the method is very simple, is not readily understood, and it
has usually been unsatisfactory. The dipper, a useful portion of the
equipment, makes an extra utensil to be kept clean. Women who
do all their own housework, take care of their own children, and
perhaps take in outside work have but little time for attention to
the details of infant-feeding. The easiest way, naturally, has for
them many attractions. Among these patients mv best success
has been in the use of full milk. They know how to shake the bottle
and measure out the milk and mix it with water or barley-water,
in the amount to be fed to the baby. Further than this, their
comprehension frequently does not extend, and, again, this is very
easily done.
As will readily be perceived, the feeding of diluted full milk
gives a food poor in fat. This we endeavor to make up by using
three times a day one-half teaspoonful or one teaspoonful of pure
cod-liver oil, for which there is no charge at the dispensary.
The following formulas and instructions for bottle-feeding are
taken from the Rules for the Care of Infants and Young Children
which are used in my service at the out-patient department of the
Babies' Hospital, and give the simplest and easiest means of bottle-
feeding.
" Bottlc-fccdinq: The bottle should be thoroughlv cleansed
with borax and hot water (one tablespoonful of borax to a pint of
water) and boiled before using. The nipple should be turned inside
out, scrubbed with a brush, using hot borax water. The brush
should be used for no other purpose. The bottle and nipple
should rest in plain boiled water until wanted. Never use grocery
milk. Use only bottled milk which is delivered every morning.
From May ist to October ist the milk should be boiled five minutes
immediately after receiving. Children of the same age vary greatly
as to the strength and amount of food required. A mixture, when
prepared, should be put in a covered glass fruit- jar and kept on the
ice. For the average baby the following mixtures will be foimd
useful :
" For a child under six weeks of age: Nine ounces of milk, twenty-
seven ounces of barley-water, four teaspoonfuls of granulated
sugar. Feed from two to three ounces at two and one-quarter-
hour intervals, nine feedings in twenty-four hours.
"Sixth to the twclftJi week: Twelve ounces milk, twenty-four
ounces barley-water, five teaspoonfuls sugar. Feed from three
to four ounces at each feeding.
"Third to the sixth month: Eighteen ounces of milk, thirty
SUBSTITUTE BREAST-FEEDING; ARTIFICIAL FEEDING 93
ounces of barley-water, six teaspoonfuls of sugar. Feed four to six
ounces at three-hour intervals, seven feedings in twenty-four hours.
''Sixth to the ninth month: Twenty-four ounces milk, twenty-
four ounces barley-water, six teaspoonfuls granulated sugar. Feed
six to eight ounces at three-hour intervals, six feedings in twenty-
four hours.
''Ninth to twelfth month: Thirty-eight ounces milk, twelve
ounces barley-water, six teaspoonfuls of granulated sugar. Feed seven
to nine ounces at three and one-half hour intervals, five feedings
in twentv-four hours.
"Condensed Milk: When the mother cannot afford to buy
bottled milk from the wagon, when she has no ice-chest or cannot
afford to buy ice, she should not attempt cow's-milk feeding, but
may use canned condensed milk as a substitute during the hot months
only. The can, when opened, should be kept in the coolest place
in the apartment, carefully wrapped in clean white paper or in a
clean towel. The feeding hours are the same as for fresh cow's
milk.
" Under three months of age: Condensed milk one-half to one
teaspoonful ; barlev- water, two to four ounces.
" Third to sixth month: Condensed milk, one to two teaspoonfuls ;
barley-water, four to six ounces.
"Sixth to ninth month: Condensed milk, two to three teaspoon-
fuls ; barley-water, six to eight ounces.
"Ninth to twelfth month: Condensed milk, three teaspoonfuls;
barley-water, eight to nine ounces."
A cereal water is used as a diluent in all of these cases, as it
increases the nutritional value of the food. One-half ounce barley
flour to a pint of water gives a nutritional equivalent of:
0.07 percent fat ;
0.3 percent total proteid;
2.0 percent carbohydrate.
Changes Needed in Hot Weather.— It wdll be seen that the
foregoing whole-milk formulas are poor in fat, as previously stated,
but during the hot months they contain as much fat as the aver-
age tenement child can safely digest without danger of producing
diarrhea. During the cooler months of the year the child is given
pure cod-liver oil from the dispensary in order to make up for
the deficient fat content of the food. During the eight months
from October ist to June ist the child is fed in this way. About
June I St the conditions of the family are investigated as to their
ability to care for the milk during the hot weather. If they have
ice-boxes and can afford ice they are instructed to continue with the
milk, but instead of giving it raw, as previously, they are told to
boil it three minutes. When they cannot supply sufficient ice to
care for the milk, they are put into the condensed-milk class. A
fairly satisfactory infant milk may be obtained in New York city
94 NUTRITION AND GROWTH
for eight cents a quart. There are parents in New York, however^
who cannot afford even this daily expenditure for the infant's milk,
or who claim that they cannot, which amounts to the same thing,
as far as the infant is concerned. The infant has to be fed. A
ten-cent can of condensed milk will last an infant three days, and
it will keep safely for use for that length of time after opening. It is
always given in a cereal water diluent in order to increase its nutritive
value, and pure cod-liver oil furnished by the dispensary is given
eight months in the year to increase the daily amount of fat. This,
of course, is anything but an ideal means of infant-feeding. Many
children thrive on it, however, but they almost invariably show some
signs of malnutrition, and offer less resistance to illness of every
nature. In spite of these drawbacks it is the best food for a con-
siderable number of children during the summer months under
existing conditions in New York city.
Adapted Milk. — In adapting milk for infant-feeding the milk
is not only "modified" (page 8i), by which process the nutritional
elements are changed in their proportions so as to make them con-
form as nearly as possible to mother's milk, but more is required
— the food must be adapted to the child's digestive capacity.
If the modification of milk, as we understand it, constituted all
that was required in infant-feeding, the artificial feeding of infants
would be a comparatively simple matter. Some infants will take read-
ilv anv reasonable modification which by experience has been found
suitable for children of their age. In others, which includes the
majority, the child fed on cow's milk has to be fed according to his
digestive capabilities. Every feeding case must be studied from
its own individual standpoint. How best to nourish the individual
patient can be learned only by a study of the patient himself. No
process of manipulation by the addition of chemicals or gruels can
convert cow's milk into human milk. There are various means
available, however, sufficient to overcome the existing differences,
thereby making cow's milk a suitable food even for those who at
first show signs of marked intolerance of it. The strength and
the feeding intervals required for the different ages in average well
children are found in the chapters on Modified Milk, page 8i.
Symptomatic Adaptation. — If the child is getting a suitable food
strength at proper intervals and the food causes illness, the difficulty
may rest either with the food as a whole, it being beyond his digestive
capacity, or there may be an incapacity for one or more of its nutri-
tional elements. If the food as a whole is too strong, there is very apt
to be vomiting, which may become habitual, or there may be colic or
constipation or diarrhea. If the food as a whole is too w^eak, it will
be evidenced by hunger, a failure to gain in weight, and usually by con-
stipation. If sugar is given in excess — a comparatively rare cause of
trouble, if not more than 7 percent of milk-sugar is given — it will be in-
SUBSTITUTE breast-feeding; ARTIFICIAL FEEDING 95
dicated by the regurgitation of sour, watery material. A sour odor to
the patient's breath and to his clothing indicates sugar excess. There
may not be pronounced vomiting in such a case, but the repeated
regurgitation when the patient is awake is sufficient to deprive him
of a goodly amount of his daily food, or the digestion of both fat
and proteid may be markedly interfered with, and the whole digestion
deranged as a result of what was primarily a sugar incapacity or
sugar excess. When sugar is at fault, the indigestion may readily
be corrected by washing out the stomach for a few days (page 180)
and by reducing the sugar content of the food one-half. Later,
after the condition is relieved, the sugar may gradually be increased
to the normal percentage of seven. A child may be getting but a
2 percent cow's-milk-fat mixture and yet suffer from fat indigestion.
Excessive fat or fat incapacity also gives rise to vomiting and re-
gurgitation in which particles of fat may often be seen. Fat may
cause also frequent green undigested stools, the passage of which is
associated with marked tenesmus. Fat-diarrhea is often the out-
come of fat-indigestion. Cow's-milk fat was not intended for babies,
and when it disagrees we cannot change its character — our only
method of adaptation is to reduce the amount given, the same as
with the sugar.
The casein in cow's milk is its important nutritional factor, and
in adapting cow's milk to a child's digestive capacity it is oftentimes
a most difhcult factor to deal with. Temporarily it may be reduced
with safety to a percentage considerably below that of cow's milk —
to 0.25 percent, for instance — but it must be remembered that the
patient cannot thrive or even long exist without this proteid
element in the diet, so that a reduction will always be followed
by malnutrition. It is necessary, then, to give proteid, and suc-
cessful infant-feeding means that we must change it through adap-
tation to the child's digestive capacity, and this, fortunately, is often-
times possible.
The Use of Alkalies and Antacids. — The casein of human milk
when it enters the infant's stomach divides into small flocculent
masses. Cow's milk entering the infant's stomach, without an
addition of an alkali or other influencing medium, is precipitated
by the pepsin in the stomach and forms a heavy curd, which consists
of paracasein, at which the child's stomach oftentimes rebels, as it
fails of digestion or assimilation. The adaptation of the casein of
cow's milk to the child's digestive capacity so as to maintain suitable
nutrition, is a central point around which the whole subject of infant-
feeding revolves. It will be noted in the formulas for cow's-milk
feeding for different ages that lime-water is used as a diluent.
This is used not simply as a diluent of cow's milk nor to render the
milk alkaline, as has frequently been stated ; it is used to prevent the
coagulation of the casein and the resulting formation of tough curds
96 NUTRITION AND GROWTH
of paracasein. Simple dilution with water may make a smaller
curd, but it does not produce the peculiar flocculent character
peculiar to human milk that follows the addition of alkalies and
antacids to cow's milk. In the presence of an alkali the casein does
not combine with the acid in the stomach, consequently the resulting
acid coagulation does not take place, hence alkalies and antacids are
added to cow's milk.
Recently, Poynton, of London, advocated the use of citrate of
soda with a view of preventing the solid coagulation of the casein.
It is claimed that by using citrate of soda, one grain to the ounce,
sodium paracasein is produced, which is a fluid. Citric acid is
liberated and unites with the calcium, forming the citrate of calcium,
which is absorbed.
Signs of indigestion of the casein in the milk are usually pain
and discomfort. There are usually acute attacks of colic. There
may be constipation or diarrhea alternating with constipation,
associated with the passage of many hard curds in the stools, the
patient losing steadily in weight. In such instances the best means
of adaptation consists in reducing the amount of proteid to a total
of I percent by dilution wnth water, and the addition of sufficient
alkalies, such as lime-water, bicarbonate of soda, or citrate of soda,
to form a curd more readily attacked by the digestive juices.
Whey-feeding. — Whey mixtures may be of temporary use in these
cases. In whev the casein is largely removed — about 0.3 percent
remaining. Analyses of whey show a nutritional equivalent of about :
0.5 percent fat;
0.9 percent lactalbumin;
0.3 percent casein;
4.5 percent sugar.
As whey is ordinarily made, it is impossible to obtain a lower per-
centage of casein than 0.25. The amount of casein will often-
times reach 0.5 percent unless it is heated and strained a second
time. The deficiency in fat may be overcome by adding gravity
cream (page 107) of the same age as the milk from which the whey
is obtained, in the proportion of one or two ounces to a pint
of whey. This, of course, carries with it a very small amount of
casein, which may make a total beyond the child's digestive capac-
ity. Low proteid must be given onlv during acute illness or in those
digestively ill, and should be a diet for temporary purposes until
the child is able to care for a more suitable nourishment. My best
results with the whey-proteid feeding have been in my laboratory
cases. During the past winter I fed nineteen infants in this way on
the Walker-Gordon milk, the casein being given at a minimum at
first — 0.3 percent with 0.9 percent lactalbumin. Later it was gradu-
ally increased as the child showed that he could assimilate it.
SUBSTITUTE breast-feeding; artificial feeding 97
Adaptation by the Use of Cereal Gruels.— It is claimed by many
excellent observers that the use of cereal gruels causes a mechanical
division of the casein, and it is thus more readily acted upon by
the digestive juices. While I use gruels as milk diluents largely,
and frequently as milk substitutes, I have yet to be convinced that
in difficult feeding cases they possess any great value in the adapta-
tion of casein to the child's digestive capacity. They are valuable
adjuncts to the diet in cases in which weak-milk foods must be given,
but I do not recall a case, nor can I find one among my records,
where I thought the use of a stronger casein possible because of the
cereal water diluent. Repeated trials with gruels, in delicate or in
marasmic infants, who afford the crucial tests in any milk adaptation,
have never enabled me to give a stronger milk proteid because of
their presence. Having fed gruels as diluents in a large number
of cases for years, I have had abundant opportunity to see enormous
curds vomited and passed by the rectum by children on a milk and
gruel diet in spite of test-tube demonstrations of the minute division
of the curd when the milk was treated with gruels. The advantage
of a cereal diluent lies in the fact that a greater amount of food is
given, both types of enzyme being made use of.
Adaptation through Peptonization. — When a child has a casein
incapacity to such a degree that he is not able to take cow's milk
when properly diluted and given at suitable intervals, the peptoniza-
tion of milk (page 115) may aid us, although I have frequently been
sorely disappointed in its use. Theoretically, peptonization — the
predigestion of the food — should be a solution of many digestive
problems. Its efficiency in actual use can be learned from mortality
statistics of children under two years of age in large cities, an immense
proportion of the deaths being due to nutritional errors either primar-
ily or secondarily. Not every infant, of course, is given peptonized
milk; but if it possessed the value claimed for it by some of its
advocates, the demand would be such as to compel its universal
use and difficult feeding cases would be no more.
Perhaps I treat five or six cases of casein indigestion a year in
which peptonization is unquestionably valuable. In using pep-
tonized milk the proteid strength should be reduced to i percent —
the lowest point compatible with safety. The amount and intervals
of feeding should correspond with those suggested for the age of
the patient. I have found the following method the best: Fifteen
minutes before nursing the bottle is rem.oved from the ice and from
one-eighth to one-fourth of a tube (Fairchild's peptonizing tube),
depending upon the amount of milk in the bottle, is added. The
bottle is then placed in water sufficiently heated, 110° to 120° F.,
to make it the right temperature for a child at the end of ten minutes.
The degree of the temperature of the water must of necessity vary
7
98 NUTRITION AND GROWTH
according to the temperature in the bottle and the amount to be
heated.
Malt-soup Feeding. — Recently several cases of malnutrition due
to difficult feeding have been under my observation in whom "malt
soup" furnished a satisfactory diet when every other means had
failed. The cases were those in which the child was of slow growth
due to faulty assimilation without the presence of vomiting or
diarrhea.
The malt soup is prepared from "Loeflund's Malt Soup-extract,"
a preparation of malt and potassium carbonate — Keller's formula.
The directions for the preparation of the food are as follows :
" Three and one-half ounces of Malt Soup-extract are added to one
pint of warm water and dissolved. This is solution No. i. Then
suspend or mix three ounces by measure or two ounces by weight
of wheat flour in one pint of milk. When the wheat flour and milk
solution is strained it is added to the Malt Soup-extract solution
and slowly brought to a boil, being stirred constantly over a slow Are.
"For young and weak children dilute the Malt Soup with one-
third part water."
In not a few instances I found it necessary to give the malt soup
with equal parts of water at the beginning of its use.
COWS MILK
As cow's milk furnishes the most available basis of nutrition for
the infant who is to be deprived of the mother's milk, it is necessary,
in order to secure the best results in its use as an infant food, that
it contain total solids between 12 and 13 percent, and that the solids
be represented in the nutritional elements in somewhat the following
proportions :
Fat 3.5 to 4 percent
Sugar 4 to 4.5 "
Total proteid. 3 to 4 "
Ash 0.7 to 0.9
Specific gravity 1.028 to 1.033
In order that there may be a fairly constant strength of the milk,,
herd-milk is to be preferred to the product of one or two cows, as
the quality of the latter may vary considerably from day to day.
It has been demonstrated that the best cows for this purpose are
what is known as "grade cows," that is, not pure bred. Such cows
thrive better, are more easily kept healthy, and are more uniform in
the nutritional equivalent of their milk-supply than are high-class
registered herds of the Alderney or Jersey strain.
The fat of cow's milk is in the form of a fine emulsion and sepa-
rates as cream. Its character is affected by the cow's food, being
softened when some articles are fed and hardened when other kinds
of food are used.
cow S MILK
99
There are several proteids of cow's milk, of which the most
important and best known are casein, which forms the curd, and
lactalbumin, the proportion being about three parts casein to one
part of lactalbumin. In mixed milk from several cows this propor-
tion is by no means constant. The sugar of cow's milk is lactose,
which is less sweet to the taste than cane-sugar or granulated sugar
or maltose derived from starch. That cow's milk shall contain a
certain quantity of total solids, and that it shall be of a specific
gravity within certain limits, is necessary in order that it may
supply nourishment to the child. Another most important feature
to be taken into consideration is cleanliness, which naturally brings
us to a consideration of the bacteriology of milk — a large subject
which can be but briefly referred to here. Milk fresh from the
udder contains very few bacteria, particularly if the first two or
three jets from each teat are discarded. The time for bacterial con-
tamination is during the milking and while the milk remains in the
stable. Certain forms of bacteria are harmless, and it is impossible
to have a milk absolutely free from bacteria. What we need to
know is how dangerous bacteria get into the milk, and how they
cause changes that may convert it into a poison of greater or less
virulence.
Harmless Bacteria. — The souring of milk is the result of the
presence of bacteria which produce changes in the sugar of milk
with the formation of lactic acid. The "turning" of milk during a
thunder- shower is due to certain changes in the atmosphere that
aid in the development of the bacteria which convert lactose into
lactic acid.
Harmful Bacteria. — Bacteria of decomposition under conditions
favorable to their growth attack the proteid constituents of the
milk, producing putrefactive changes with evolution of poisons
which may be of the greatest virulence. The putrefactive bacteria
are always present in stables where manure is allowed to collect, and
where cleanliness is not observed. When we remember what a
culture-field milk affords to bacteria, and when we see the manner
and the surroundings in which it is usually drawn, it is not sur-
prising that it should contain many millions of bacteria to a cubic
centimeter. They may enter the milk from the dust in the stable —
a very fruitful source — or they may find entrance from the milker's
hands or from droppings of fine particles of manure from the belly
of the cow. These are among the most dangerous forms of bacteria
found in milk. When bacteria once gain entrance into the milk,
their growth is most rapid. In corroboration of this, the observa-
tion of Parsons* is most interesting and instructive. He writes as
follows :
"There is more or less dust floating in the air of houses and
' Cornell Reading Course, December, 1905.
lOO NUTRITION AND GROWTH
stables, and this dust is constantly settling. When it falls into
milk, it carries bacteria with it. If the milk is warm, these bacteria
multiply very rapidly; if the milk is cold, they may develop slowly,
but they will be ready for rapid growth as soon as the temperature is
raised. The production and care of good milk depend very much
on the care taken to prevent dust from getting into it, and the
maintaining of a low temperature after it is drawn.
"Last summer, Walter E. King, of the State Veterinary College,
and myself [Parsons], made a number of tests to determine the
importance of different sources of milk contamination. In most of
these tests a definite quantity of sterilized milk at 98° F. was exposed
to some one kind of contamination that we wished to test. The
milk was then examined, and in that way we could obtain a fairly
accurate idea of the extent of this particular kind of contamination.
Some of the experiments and their results are as follows :
" I. Exposure to Air in the Stable: Two liters (about two quarts)
of sterilized milk were placed in a sterile pail and exposed seven
minutes to the stable air in a passageway behind the cows. This
stable was doubtless cleaner than the average, and the air contained
less dust than is often found in places where milk is being handled.
Immediately after this exposure, the milk was 'planted,' and we
found it to contain 2800 bacteria per cubic centimeter (about fifteen
drops) ; in other words, between 5,000,000 and 6,000,000 bacteria
had fallen into the two liters of milk in this short time.
"2. Pouring of Milk: When milk is poured from one vessel
into another, a very large surface is exposed to the air, and great
numbers of bacteria are swallowed up. The following tests illus-
trate this point : About five liters of milk were poured from one can
to another eight times in the stable air. It was found, after pouring,
that this milk contained practically 100 bacteria per cubic centi-
meter more than it contained before pouring ; in other words, about
600,000 bacteria had gotten into the milk on account of this ex-
posure.
"In another similar experiment, when there was a little more
dust in the air, the contamination due to pouring eight times was
two and one-half times greater than in the preceding experiment.
"3. Contaminated Utensils: Much contamination of milk results
from putting it into dishes that have been cleaned and then exposed
where dust can fall into them. In experiments to determine what
this kind of contamination amounts to, it has been found that when
little care is taken to protect the dishes, the milk will often contain
several hundred times as many bacteria as when the utensils were
protected from dust. In order to illustrate this point, two pails
were carefully washed and sterilized. One of them was covered
with sterile cloth to keep dust from falling into it. The other was
left exposed for only a few minutes to the air of a clean creamery.
cow's MILK
A small quantity of sterile milk was then put into each pail, rinsed
around, and then examined for bacteria. It was found that the
milk in the pail which was not protected from dust contained 1600
more bacteria per cubic centimeter than the milk in the protected
pail.
"4. Contamination from the Cow's Udder and Body: Great num-
bers of bacteria fall into the milk when it is being drawn, because
the milking-pail is directly under the udder, which is being shaken
more or less by the milker. This kind of contamination may be
reduced by cleaning the udder. For example, it was found that
sterile milk, exposed under the udder as long as it takes to milk a
cow, while the udder was being shaken about the same as when
milk is being drawn, contained 19,000 bacteria per cubic centimeter.
M-
Fig. 12.
Figs. 12, 13.— Milk Pails.
Fig- 13-
In this case the udder had been wiped off with a dry cloth in much the
same way as is done in fairly good dairies.
" In a similar test the udder was wiped with a damp cloth, when
the number of bacteria was reduced to 4500 per cubic centimeter.
In a third experiment the udder was wiped with a cloth dampened
in a 4 percent carbolic acid solution, when the number of bacteria
was found to be 3200 per cubic centimeter. In cases where no
particular care is taken to clean the udder, the bacteria getting into
the milk from this source may run up into the millions.
"5. Importance of Small Openings in Milk Pails: (See Fig. 12.)
From the experiments above mentioned, it will be seen that it is
impracticable to clean the udder or free the air from dust so per-
fectly that no bacteria will fall into the milk. The next question is.
I02 NUTRITION AND GROWTH
How can we reduce the number of those that will fall in, despite all
reasonable precautions? The easiest way known is to use a small-
top milking-pail, thus reducing the size of the opening through
which dirt can fall in. An experiment to illustrate this point
showed that milk drawn into an ordinary milking-pail contained
1300 bacteria per cubic centimeter; while that drawn into a pail
with an opening about one-half as wide, contained only 320 bacteria
per cubic centimeter. This is exactly proportionate to the number
of square inches of exposed surface in the two pails. For example,
a pail having a circular top fourteen inches in diameter has an
opening of 153.86 square inches; a pail with a twelve-inch top has an
opening of 11 3.04 square inches ; one with a ten-inch top has an open-
ing of 79.79 square inches; and a pail with an opening six inches in
diameter has an exposure of 28.26 square inches. (See Fig. 13.)
" Milkers should get into the habit of using the small-top pail,
as it is one of the easiest of all ways of reducing the number of bac-
teria that fall into the milk.
" 6. Contamination by Flies: A fly or a bit of hay or straw or a
piece of sawdust or a small hair may carry enormous numbers of
bacteria into milk, as is shown by the following experiments:
"A living fly was introduced into 500 c.c. of sterile milk. The
milk was shaken one minute, when it was found to contain 42 bac-
teria per cubic centimeter. After twenty-four hours at room-
temperature, it contained 765,000 bacteria per cubic centimeter,
and after twenty-six hours, 5,675,000.
"7. Dirt in the Milk: A piece of hay about two inches long was
placed in 500 c.c. of sterile milk. The milk was shaken one minute,
when it contained 3025 bacteria per cubic centimeter. After
twenty-four hours at room-temperature, it contained 3,412,500
bacteria per cubic centimeter.
" One piece of sawdust from the stable floor was put into 500 c.c.
of sterile milk. The milk was shaken one minute and its bacterial
content was then found to be 4080 per cubic centimeter. After
twenty-four hours at room-temperature it was 7,000,000 per cubic
centimeter.
"A hair from a cow's flank was put into 500 c.c. of sterile milk.
After shaking the milk for one minute it contained 52 bacteria per
cubic centimeter. After twenty-four hours at room-temperature it
contained 55,000 per cubic centimeter, and after thirty-six hours,
over 5,000,000 bacteria per cubic centimeter."
The results of the foregoing observations are given in detail,
in order to impress upon the reader the necessity of exerting his
energies to the end that the infants under his care may receive a
less contaminated milk-supply.
Market Milk. — The legal standards for pure milk in most instances
relate only to the chemical composition of the milk. The laws of
cow S MILK 103
most of the States call for 12 percent of total solids, and at least 3
percent of fat. If the milk contains less than these percentages it is
considered impure, even if it is just as it was when it left the cow's
udder. Some cows give milk considerably below this standard.
The chemical analysis of milk does not show whether it is suitable
for use as an infant food, this point being decided according to its
freshness and the care with which it has been handled with reference
to the exclusion of bacteria and the prevention of their growth.
The production of clean, safe milk is expensive. It costs at
least two cents a quart to produce milk, without allowing anything
for the labor of caring for the cows. The milk must be carried to
the consumer, which is also expensive. Yet, in New York city, milk
that possesses the legal requirements retails in the grocery stores,
during the summer months, at 3^ cents a quart— two quarts for
seven cents. This milk is known as "grocery milk," and is a very
poor food for infants. It is teeming with bacteria, as little care is
taken in its production.
The next grade of milk is sold in quart bottles which have been
filled in the country, packed in cracked ice, and shipped to the city.
The milk contains many bacteria, but is far better than grocery
milk. It is retailed to the consumer for about eight cents a quart.
Certified Milk.— The best grade of milk, and the one which
should be used in feeding infants whenever possible, is known
as "certified milk," and is produced under the direction of what
is known as a "milk commission." The estabhshing of "m_ilk
commissions" in different cities throughout the country has been
the means of securing a much better milk-supply than was form-
erly possible, and has doubtless been instrumental in saving many
lives. To Dr. H. L. Coit, of Newark, N. J., is due the credit of
organizing the first milk commission. Certified milk must conform
to certain standards as to its nutritional value, and as to the num-
ber of bacteria per cubic centimeter. These standards are estab-
lished by a committee of medical men who compose the milk com-
mission and who have complete control of the dairy and its entire
output.
The Milk Commission of the New York County Medical Society
required a standard of milk not exceeding 30,000 bacteria in a cubic
centimeter. When a dairyman has shown to the satisfaction of the
Commission that he can produce a milk up to the required standard,
he is allowed to attach to his bottles of milk labels furnished by the
Commission certifying to that fact. Milk thus "certified" is taken
from the delivery wagons from time to time and subjected to exami-
nation by their bacteriologist in order to determine w^hether it
conforms to the requirements of the Commission. In order to show
the care and supervision necessary for the production of certified
milk, the requirements of the Milk Commission of the New York
I04 NUTRITION AND GROWTH
County Medical Society for the Production of "certified milk" are
given in full : ^
"The most practicable standard for the estimation of cleanliness
in the handling and care of milk is its relative freedom from bacteria.
The Commission has tentatively fixed upon a maximum of 30,000
germs of all kinds per cubic centimeter of milk, which must not be
exceeded in order to obtain the indorsement of the Commission.
This standard must be attained solely by measures directed toward
scrupulous cleanliness, proper cooling, and prompt delivery. The
milk certified by the Commission must contain not less than 4 percent
of butter fat on the average, and must possess all the other charac-
teristics of pure, wholesome milk.
"In order that dealers who incur the expense and take the pre-
cautions necessary to furnish a truly clean and wholesome milk may
have some suitable means of bringing these facts before the public,
the Commission offers them the right to use caps on their milk jars
stamped with the words : 'Certified by the New York County Medical
Society Milk Commission.'
"Rules for the Producer. — i. Tlie Barnyard. — The barnyard
should be free from manure and well drained, so that it may not
harbor stagnant water. The manure which collects each day should
not be piled close to the barn, but should be taken several hundred
feet away. If these rules are observed not only will the barnyard
be free from objectionable smell, which is always an injury to the
milk, but the number of flies in summer will be considerably dimin-
ished. These flies, in themselves, are an element of danger; for they
are fond of both filth and milk, and are liable to get into the milk
after having soiled their bodies and legs in recently visited filth,
thus carrying it into the milk. Flies also irritate cows, and by
making them nerv^ous reduce the amount of their milk.
"2. The Stable. — In the stable the principles of cleanliness must
be strictly observed. The room in which the cows are milked should
have no storage loft above it; where this is not feasible, the floor of
the loft should be tight, to prevent the sifting of dust into the stable
beneath. The stable should be well ventilated, lighted, and drained,
and should have tight floors, preferably of cement. They should
be whitewashed inside at least twice a year, and the air should always
be fresh and without bad odor. A sufficient number of lanterns
should be provided to enable the necessary work properly to be done
during dark hours. There should be an adequate water-supply
and the necessary wash-basins, soap, and towels. The manure
should be removed from the stalls twice dailv, except when the
cows are outside in the fields the entire time between the morning and
afternoon milkings. The manure gutter must be kept in a sanitary
condition, and all sweeping and cleaning must be finished at least
^Chapin: "Infant Feeding."
cow's MILK lO-
twenty minutes before milking, so that at that time the air may be
free from dust.
"3. Water-supply. — The whole premises used for dairy purposes,,
as well as the barn, must have a supply of water absolutely free frorn
any danger of pollution with animal matter, sufficiently abundant
for all purposes, and easy of access.
"4. The Cows. — The cows should be examined at least twice a
year by a skilled veterinarian. Any animal suspected of being in
bad health must be promptly removed from the herd and her milk
rejected. Never add an animal to the herd until it has been tested
for tuberculosis and it is certain that it is free from disease. Do not
allow the cows to be excited by hard driving, abuse, loud talking,
or any unnecessary disturbance. Do not allow any strongly flavored
food, like garlic, which will affect the flavor of the milk, to be eaten
by the cows.
"Groom the entire body of the cow daily. Before each milking
wipe the udder with a clean, damp cloth, and, when necessar}^
wash it with soap and clean water and wipe it dry with a clean towel.
Never leave the udder wet, and be sure that the water and towel
used are clean. If the hair in the region of the udder is long and not
easily kept clean, it should be clipped. The cows must not be
allowed to lie down, after being cleaned for milking, until the milking
is finished. A chain or rope must be stretched under the neck to
prevent this.
"All milk from cows sixty days before and ten days after calving
must be rejected.
"5. The Milkers.— The milker should be personally clean. He
should neither have nor come in contact with any contagious disease
while employed in milking or handling milk. In case of any such
illness in the person or family of any employee in the dairy, such
employee must absent himself from the dairy until a physician
certifies that it is safe for him to return.
"Before milking, the hands should be thoroughly washed in
warm water with soap and a nail-brush and well dried with a
clean towel. On no account should the hands be wet during the
milking.
" The milking should be done regularly at the same hour morning
and evening, and in a quiet, thorough manner. Light-colored
washable outer garments should be worn during milking. Thev
should be clean and dry, and when not in use for this purpose should
be kept in a clean place protected from dust. Milking-stools must
be kept clean. Iron stools, painted white, are recommended.
"6. Helpers Other than Milkers. — All persons engaged in the
stable and dairy should be reliable and intelligent. Children under
twelve years should not be allowed in the stable during milking,
since in their ignorance they may do harm, and from their liability
Io6 NUTRITION AND GROWTH
to contagious diseases they are more apt than older persons to
transmit them through the milk.
" 7. Small Animals. — Cats and dogs must be excluded from the
stable during the time of milking.
"8. The Milk. — The first few streams from each teat should be
discarded, in order to free the milk-ducts from milk that has re-
mained in them for some time and in which bacteria are sure to have
multiplied greatly. If, in any milking, a part of the milk is bloody
or stringy or unnatural in appearance, the whole quantity of milk
yielded by that animal must be rejected. If any accident occurs by
which the milk in a pail becomes dirty, do not try to remove the
dirt by straining, but reject all the milk and cleanse the pail. The
milk-pails used should have an opening not exceeding eight inches
in diameter.
"Remove the milk of each cow from the stable, immediately
after it is obtained, to a clean room, and strain it through a sterilized
strainer.
"The rapid cooling of milk is a matter of great importance.
The milk should be cooled to 45° F. within one hour. Aeration of
pure milk beyond that obtained in milking is unnecessary.
"All dairy utensils, including bottles, must be thoroughly
cleansed and sterilized. This can be done by first thoroughly
rinsing in warm water, then washing with a brush and soap or other
alkaline cleansing material and hot water, and thoroughly rinsing.
After this cleansing, they should be sterilized with boiling water
or steam, and then kept inverted in a place free from dust.
"9. The Dairy. — The room or rooms w^here the bottles, milk-
pails, strainers, and other utensils are cleaned and sterilized should
be separated somewhat from the house, or when this is impossible
have at least a separate entrance, and be used only for dairy purposes,
so as to lessen the danger of transmitting through the milk contagious
diseases which may occur in the home.
"Bottles, after filling, must be closed with sterilized discs and
capped so as to keep all dirt and dust from the inner surface of the
neck and mouth of the bottle.
" 10. Examination of the Milk and Dairy Inspection. — In order
that the dealers and the Commission may be kept informed of the
character of the milk, specimens taken at random from the day's
supply must be sent weekly to the Research Laboratory of the
Health Department, where examinations will be made by experts
for the Commission, the Health Department having given the use
of its laboratories for this purpose.
"The Commission reserves to itself the right to make inspections
of certified farms at any time and to take specimens of milk for
examination. It also reserv^es the right to change its standards in
any reasonable manner upon due notice being given the dealers."
CREAM 107
Naturally, milk produced in this way is more expensive than when
little or no care is used, more help is required, and help of a more
expensive type. Certified milk, or its equivalent, is sold in New
York city at prices ranging from twelve to eighteen cents a quart.
Examination of Cow's Milk. — In cow's milk, as in human milk,
a chemical analysis is necessary in order to know accurately the
nutritional elements. The specific gravity varies from i .029 to i .035.
Milk is acid in reaction to phenolphthalein, and may be neutral to
litmus. The Babcock milk-test machine is what is generally em-
ployed in examining cow's milk in laboratories and institutions.
The test consists in mixing the milk with strong sulphuric acid which
dissolves the proteids and liberates the fat, the quantity of which
is read off from the graduated neck of the bottle used in mixing the
milk and acid. Only the fat is determined in this way. Knowing
the fat and the specific gravity, the solids other than fat may readily
be determined by adding to one-fourth of the specific gravity, reading
to the right of the decimal point, one-fifth of the percentage of fat.
CREAM
Market creams are known as "gravity cream" and "centrifugal
cream."
Gravity Cream. — Gravity cream is obtained by allowing the milk
to stand for a certain length of time and then removing the cream.
When milk, as soon as it is drawn, is placed in a quart milk-bottle or
fruit- jar and kept at a temperature of between 40° and 50° F., most of
the fat will have risen at the end of five hours. When the cream is
carefully removed at the end of this time, from 0.3 to 0.8 percent of
fat will remain in the milk. The fat content of gravity cream is
subject to considerable variation, depending, of course, upon the
richness of the milk and the manner in which it is treated, particularly
as relates to rapid cooling. In the cream from well-kept grade cows
the fat will average about 16 percent. In cream from w^ell-fed
Aldemey or Jersey herds it may be as high as 20 percent, or higher.
In cream from cows indifferently fed, in those who subsist entirely
upon poor pasturage, the fat may be as low as 10 or 12 percent. For
infant-feeding, gravity cream from the milk of grade cows is preferred.
In using cream for infant-feeding all the cream to the milk line should
be removed, as the upper layers are much richer in fat than that
adjoining the milk. Further, when cream is mixed with milk both
must be of the same age, as the addition of older bacteria-laden
cream to fresh milk will surely result in grave digestive disorders.
Centrifugal Cream. — Centrifugal cream is that which is removed
by an apparatus known as a separator, which consists of a circular
bowl for holding the milk so arranged as to make from 3000 to 5000
revolutions a minute. This results in a rapid separation of the
lighter fat from the milk. The fat collects near the center of the
Io8 NUTRITION AND GROWTH
bowl and is removed by a device arranged for this purpose. The
skimmed milk flows outward from another portion of the bowl by a
similar device. Centrifugal cream is more difficult of digestion than
gravity cream in that the natural emulsion in which the fat is h(^ld
in the milk is destroyed by the process of centrifuging. Centrifugal
cream may vary greatly in its fat content, depending upon the
rapidity of operation of the separator. According to Babcock and
Russell, the proteids also undergo a change, which does not add to
their nutritive value.
DIFFICULT FEEDING CASES
Under this heading will be considered the acutely difficult cases^
those seen in the newly born or during the first month of life. Maras-
mus and malnutrition will not be referred to here, as these sub-
jects are considered under their respective headings.
Not a few healthy infants for whom the breast-feeding is impos-
sible show intolerance of cow's milk even when it is given very much
diluted with lime-water or otherwise. In these infants the intoler-
ance is usually of the casein of the cow's milk. The child suffers from
colic, oftentimes to an extreme degree, crying five or six or more
hours out of every twenty-four. Generally there is constipation. The
stools are usually hard and dry, and when passed, are often composed
of broken masses of fecal matter. In some, however, there will be
loose watery stools containing many milk curds. The abdomen is
usually distended and there may be vomiting, but this is seldom
an active symptom. The child remains stationary or loses in weight.
If suitable nutrition is not forthcoming, he rapidly develops a con-
dition of malnutrition or marasmus.
Treatment. — Whey-feeding. — In some of these infants the feeding
of whey (page 96) or cream largely diluted may be successful (page
87). In not a few, however, the small amount, about 0.3 percent,
of casein w^hich cannot be removed from the whey is sufficient to
cause marked symptoms of indigestion. The addition of citrate of
soda (page 96) may be attempted here for the purpose of facilitating
the digestion of the casein. A few days' trial may determine
whether it will be of any service.
The Wet-nurse.— The use of peptonized milk mixtures is rarely
successful with these infants. If the whey or diluted cream or the
peptonization of the food is not successful, I invariably advise a wet-
nurse, if the family can afford the so-called luxury. It is important
in the management of one of these cases for the physician to know
when he is beaten. A case should never be experimented with to
the point of marasmus and exhaustion before securing a wet-nurse,
for by this time the digestion may be so thoroughly deranged that
her milk will fail to nourish the child.
Condensed Milk. — When the wet-nurse is impossible, it is not wise
DIFFICULT FEEDING CASES
109
to attempt the forcing of fresh cow's milk or cream mixtures. Con-
densed milk should now be resorted to. The proteid of condensed
milk is often very readily assimilated by the most delicate infant and
furnishes a valuable means of nutrition in not a few cases until the
infant is able to digest better food. It is to be understood, however,
that condensed milk is but a temporary expedient. The infants will
take it with comfort, and temporarily will thrive on it, oftentimes
when cow's milk in any dilution or process of adaptation is impossible.
When beginning the use of condensed milk it is best to begin with
small quantities — not more than one dram in the boiled water diluent
of two or three ounces. In some cases, at first, even one-half dram
answers better. Later the strength may be increased to from two to
four drams if it is found to agree, the amount depending somewhat
upon the age of the patient. When the condensed milk is found to
agree, in order to give as much nourishment as possible, No. i
barley-water or Granum- water (page 124) may be used as a diluent.
Cow's Milk. — When the child has remained comfortable for three
or four weeks on some such scheme of feeding, with or without a gain
in weight, one feeding daily of a cow's-milk mixture may replace a
feeding of condensed milk. A cow's-milk mixture should always be
given of a weaker strength than the child's age calls for. In spite
of the dilution it may occasion indigestion, colic, and the passage of
curds. In such an event the condensed milk and its diluent must
again be the sole diet for two or three weeks, when the use of cow's
milk may again be attempted. In case this one feeding of cow's milk
is taken without inconvenience, a second feeding may replace another
condensed-milk feeding in a few days or a week. In this way the
number of cow's-milk feedings may gradually be increased until the
child is taking a rational diet of cow's milk alone. I have a most
difficult feeding case under my care at the present time. A six-
months-old baby is taking daily three feedings of condensed milk
and three of cow's milk. Attempts have been made to give him the
fourth feeding of cow's milk, but invariably with disastrous results.
He is slightly under weight, but is in a fair general condition.
I have successfully managed a great many of these difficult
feeding infants as described above, the cow's-milk feeding not being
commenced until the condensed milk is W'Cll taken and the child
gaining, when the cow's-milk feeding is gradually advanced so that
when the child is three months old it will be taking daily and assim-
ilating two or three feedings of cow's milk ; when six months old and
sometimes earlier, he will be on entire cow's-milk feedings suitable
for his age . I have found this meets better the desired end of complete
cow's-milk feeding, and it is thus reached sooner than when small
quantities of cow's milk are added to the condensed-milk mixture.
In beginning the cow's milk it is best to give it at the first
or second feeding in the morning, when the digestive powers are
no NUTRITION AND GROWTH
stronger than they are later in the day. When the second cow's-milk
feeding is given it should never immediately follow the first. The
cow's milk and the condensed milk should be alternated until more
than one-half of the daily feedings are of cow's milk.
Idiosyncrasies as to Cow's Milk. — At rare instances, cases are
encountered in which there exists an intolerance of cow's milk or
any form of food w^hich contains cow's milk, including condensed
milk, and all the malted foods containing desiccated cow's milk.
In such cases the use of any of these substances as foods produces
illness of such an alarming type as to necessitate its prompt discon-
tinuance. The only hope for infants thus constituted is a wet-nurse.
Illustrative Cases. — The best illustration of milk idiosyncrasy that
I have observed occurred in my own family. A healthy full-term
female infant whose birth-weight was seven pounds twelve ounces was
nursed by her mother with indifferent success for two weeks, when the
supply failed absolutely. Feeding with a most carefully prepared
modified cow's milk was begun. The child refused the food and two
drams were forced. This was followed, in a few moments, by vomiting
and retching, which continued at intervals for twenty-four hours, with
collapse and exhaustion to an extreme degree. A wet-nurse was
secured, the breast was well taken, and the milk agreed perfectly.
In three days the wet-nurse's milk began to fail and was entirely
lost in twenty-four hours. A weak dilution of condensed milk was
then given, with results almost as disastrous as before. The child
at this time weighed six pounds four ounces and showed all the
symptoms of early marasmus. A second wet-nurse was secured,
whose milk also failed in a few days. Before dismissing her, however,
a third was engaged, on whose milk the child thrived most satisfac-
torily. When three months of age a w^eak cow's-milk mixture
prepared by the Walker-Gordon Laboratory was given. The child
refused it, and one-half ounce was forced. As on the previous
occasion, vomiting with prostration bordering on collapse was the
outcome. The child vomited at frequent intervals for twelve hours
and the breast was refused for twelve hours longer. The giving of
cow's milk was not again attempted until the child was nine
months old, a wet-nurse being employed. She was then strong
and vigorous and weighed eighteen pounds. Two drams of a cow's-
milk mixture suitable for a child three months of age were given.
It produced nausea and vomiting as though an equal quantity of
syrup of ipecac had been given, but without any more serious dis-
turbance. At this time the wet-nurse's milk began to fail. The
breast-milk nutrition was assisted by the use of a cereal made into a
thick gruel. Oatmeal in the form of a gruel to which sugar was
added was given, largelv because of its high-proteid content. Beef-
juice, scraped beef, and pure cod-liver oil were also begun about
this time. When one year of age a portion of a soft &gg was added
STERILIZATION AND PASTEURIZATION OF MILK 1 I I
to the diet. Zwieback and bread crusts soaked in sugar-water were
also used. These sohd substances were given two or three times a
day, after which the child was nursed. Pure cod-liver oil was
almost continuously given during the second year. Butter fat
could be taken without inconvenience when she was one year of age.
Following out the above lines of treatment, the child was weaned
when thirteen months of age. She has since been fed with an entire
absence of cow's milk from the diet. She is now six years of age.
Her weight is fifty-five pounds, height forty-eight inches. She is
normal in every respect, but six ounces of milk given at one time
will produce a coated tongue, foul breath, constipation, and excessive
irritability, which is entirely foreign to her nature.
I had a similar experience in the case of a patient — a boy now
four years of age who has never been able to take cow's milk. He
also is above the average in weight, height, and vitality. I have
had a number of these cases which could not take milk up to the
eighteenth month or second year. I have had, in all, five cases
that could not tolerate milk in any appreciable amount until after
the fifth year was passed.
STERILIZATION AND PASTEURIZATION OF MILK
The sterilization and pasteurization of milk, as the terms imply,
are for purposes of preservation. By sterilized milk we understand
milk that is heated to the boiling-point and maintained at that
temperature, 212° F., for twenty minutes. The effect of steriHzation
is the destruction of the pathogenic bacteria, but it will not destroy
the spores. Pasteurization consists in heating the milk to 167° F.,
maintaining it at that temperature for thirty minutes, and then
quickly cooling it. The effect of sterilization and the rapid cooling
is to kill existing bacteria, thus preventing, temporarily, further
bacterial growth in the milk. The heating of milk to this high
degree of temperature, 212° F.,— the boiling-point,— produces
certain changes in the milk. The lactalbumin is coagulated, the
lime salts are rendered insoluble, and the casein is rendered much
more difficult of digestion, so that the heating of milk in this way
renders it more difficult of digestion and lessens its nutritive value.
Results of Sterilization.— Constipation is one of the unfavorable
results of sterilizing milk. The peculiar taste produced by boiling is
another of the disagreeable features connected with it. The cooking
of the milk destroys certain of its nutritional properties but little un-
derstood, the result of which may be scurvy, rachitis, or some other
form of malnutrition. Sterilization, however, is in certain conditions
necessary. The milk which is boiled in a bottle which is properly
covered "is " sterilized milk," but if the sterilization is to be carried on
day after day an Arnold sterilizer (Fig. 14) should be used. For pur-
poses of pasteurization the Freeman pasteurizer (Fig. 1 5) is recorti-
NUTRITION AND GROWTH
mended. Pasteurization makes less change in the character of the
milk content ; consequently there is less interference with its nutritive
value. The temperature, too, 167° F.. is sufficiently high to
destroy pathogenic bacteria, including the Bacterium lactis and
the Bacterium aerogenes, and hence acts as a valuable preservative,
particularly during hot weather. But heating the milk to this
degree exerts little influence in causing constipation, nor does it
change the taste of the milk.
Pasteurization Safest for Exclusive Use. — As to the feeding of
milk, whether it shall be given sterilized, pasteurized, or raw, end-
less discussion has arisen in the press and in medical societies. Each
method has its advocates. Among the pediatrists at the present
time, some contend that milk should be sterilized, regardless of the
season of the year, the character
of the milk, or the station in life of
the patient ; others maintain that
invariably it should be given raw,
regardless of the above-mentioned
conditions; while still others are
devoted to pasteurization. If any
of the methods were to be used
exclusively, pasteurization, being
the safest, should be selected.
Judging from my own experience
in the matter of the heating of
milk for infant foods, the sub-
ject should be considered from a
broad standpoint. There is no
one way of heating milk that is
invariably the best way. Ac-
cording to my observation, which
covers every class of society,
there are several factors which determine which is the proper pro-
cedure in a given case.
Raw Milk Preferred if Fresh and Pure. — There is no doubt what-
ever that the less the milk is heated, the better food it is for the
baby, assuming that it is clean when procured and can be kept clean
and sweet until it is used. (See Cow's Milk, page 98.) This is possible
in some of our dairies of the better class ; it is possible with many
who live in the country, or who go to the countrv for the summer
and who keep their own cows or who get their milk-supply from a
neighboring source which they can control. Under such conditions
the milk may be given raw during the entire year.
When the milk has to be shipped a considerable distance during
the summer, when its safety depends upon the industry and care of
the employees of a milk farm, I find it advisable to pasteurize the
Fig. 14.— Arnold Sterilizer.
STERILIZATION AND PASTEURIZATION OP MILK I 13
milk during the heated term; therefore the majority of my private
feeding cases get raw milk during eight months of the year and pas-
teurized milk four months. Sterilized milk is never used among
these patients except when preparing for an ocean voyage (see Milk
for Traveling, page 116) or for a long-distance journey by land.
Among out-patients, after feeding many thousands of them I find
the following scheme the safest: From May ist until October ist.
the milk is boiled (sterilized). These people, most of them, cannot
afford a pasteurizer or sterilizer or understand the use of either.
From October ist to
May ist, the milk is
given raw. Pasteuri-
zation would be pref-
erable, but it is possi-
ble with but very few
dispensary patients.
Even the giving of
Fig. 13.— Freeman Pasteurizer.
cooked milk, which unquestionablv often becomes infected after
cooking, is attended with no little risk to the child, as is shown
by the death records of bottle babies during the summer. The giv-
ing of the cheap market milk raw to infants of the tenements during
the heated term in any large citv can onlv help to increase the
terrible mortality of this season.
The object of heating the milk should always be explained to
the mother so that she may appreciate the necessity of keeping it
carefully covered and properly caring for it afterward. The idea
is prevalent among uninformed people that after sterilization but
little further protection is required. When I am satisfied that the
out-patients have not the intelligence or the requirements for keeping
114 NUTRITION AND GROWTH
cow's milk during the summer, such as an ice-box and ice, I discon-
tinue the ordinary milk-feeding for the hot months and use condensed
milk instead (page 94).
CONDENSED MILK
Condensed milk is in the market in three forms — fresh condensed
milk sold in bulk, condensed milk sold in hermetically sealed cans,
and evaporated cream, sold also in hermetically sealed cans. The
evaporated creams usually contain no more fat than does condensed
milk; in fact, they are condensed milk without the addition of sugar,
which acts as a preservative. They are put up in small cans and
soon become putrid after opening. Therefore the contents of a
can should be used only on the day it is opened. Of the condensed
milks, I prefer the sweetened variety, of which there are many kinds
showing slight variation in the analysis. The Eagle Brand of
Borden is that which I usually employ, an analysis ^ of which showed
it to contain :
Fat 8.8 percent
Sugar 52.2
Total proteid 9.3
Total solids 72.2
Ash 1.9
Water 27.8
The following combinations of condensed milk with barley-water
may be found useful in the various ages indicated :
Under three months of age: Condensed milk, one-half to one
even teaspoonful; barley-water, two to four ounces.
Third to sixth month: Condensed milk, one to two even tea-
spoonfuls ; barley-water, four to six ounces.
Sixth to ninth month: Condensed milk, two to three even tea-
spoonfuls; barley-water, six to eight ounces.
Ninth to twelfth month: Condensed milk, three even teaspoonfuls;
barley-water, eight ounces.
It will be seen that when condensed milk is diluted from ten to
twenty times, we have a food weak in fat and weak in proteid. It
should never be selected as a permanent diet unless poverty neces-
sitates it or unless it is the only milk food the patient can digest.
For temporary purposes it is often useful, as is shown in
different portions of this book (see index). Where cow's milk can-
not be used in a given case, and condensed milk must be continued,
it should be fortified with a cereal gruel of barley or oatmeal; pure
cod-liver oil should also be given to make up for the deficiency in fat
in the food.
'Analysis made for the author by Dr. Frederick Sondern, of New York.
PEPTONIZED MILK II5
PEPTONIZED MILK
Milk is peptonized, or predigested, for the purpose of partially
or completely digesting the proteid before it is given to the patient.
As a means of assistance in making a milk food assimilable its field
of usefulness is limited. The process referred to (page 97) has been
the one most successful with me. So-called complete peptonization
produces a product with a decidedly bitter taste, and but few children
will take it. Peptonized milk, however, has other uses than as a means
of dailv feeding. Peptonized milk in which there is a complete
conversion of the casein has been most useful in two types of cases.
For Gavage. — During acute or chronic illness when a child cannot
take food by the natural method, as in diphtheritic paralysis, or
when he will not swallow on account of an acute inflammatory
disease of the throat such as peritonsillitis, retropharyngeal abscess,
or retropharyngeal adenitis, or when he is in a comatose condi-
tion from any cause except intestinal infection, the feeding of
completely peptonized milk by gavage (page 134) is of inestimable
value. In such conditions, as a valuable aid in nutrition, frequent
reference is made to it throughout this book.
For Nutrient Enema. — In conditions when stomach-feeding is
impossible either by gavage or the natural method — conditions met
with in persistent vomiting due to acute cerebral diseases, in recur-
rent vomiting, in acute gastric indigestion — and as an accessory
means of feeding when sufifiicient nourishment cannot be taken b}^ the
stomach, the colon-feeding of completely peptonized skimmed milk
has a decided field of usefulness, and in this way I often employ it.
Feeding by means of the bowel, however, is usually possible in children
for a few days only, because of the local irritation produced by the
nutriment and by the passage of the tube. Skimmed milk, pepton-
ized, with the addition of the white of egg makes the best nutrient
enema that I have used (page 139). It should be given at a tem-
perature between 90° and 95° F. at from six to eight-hour intervals.
The tube should be introduced at least nine inches. In cases of re-
current vomiting I have repeatedly seen both hunger and thirst
relieved by feeding in this way. The following are the different
methods for the peptonization of milk.
Peptonization. — Innuediate Process. — Fifteen minutes before
feeding add from one-eighth to one-quarter of the contents of a Fair-
child peptonizing tube to the milk mixture which is in the nursing-
bottle ready for use. Place the bottle in water at a temperature of
from 110° to 120° F., and let it remain until fifteen minutes have
elapsed. The amount of the powder used and the degree of heat of
the water depend, of course, upon the amount of milk in the nursing-
bottle.
Cold Process. — Put four ounces of cold water into a clean quart
Il6 NUTRITION AND GROWTH
bottle and dissolve in it, by shaking thoroughly, the powder con-
tained in one of the Fairchild peptonizing tubes; add a pint of cold
fresh milk, shake the bottle again, and immediately place it upon ice —
directly in contact with it.
The bottle should always be well shaken before and after pouring
out a portion of its contents.
Partially Peptonized Milk. — Put four ounces of cold water and
the powder contained in one of the Fairchild peptonizing tubes into
a clean saucepan, and stir well; add a pint of cold fresh milk and
heat with constant stirring to the boiling-point. The heat should
be so applied that the milk will come to a boil in ten minutes. Let
it cool until lukewarm, then strain into a clean bottle or glass jar,
cork tightly and keep in a cold place. The bottle or jar should always
be well shaken before and after pouring out a portion.
Partially peptonized milk, if properly prepared, will not become
bitter.
Completely Peptonized Milk. — Put four ounces of cold water and
the powder contained in one of the Fairchild peptonizing tubes into
a clean quart bottle and shake thoroughly; add a pint of cold fresh
milk and shake again; then place the bottle in a pail or kettle of
warm water — about 115° F., or not too hot to immerse the hand in
it without discomfort. Keep the bottle in the water-bath for thirty
minutes. Put it immediately upon ice — directly in contact with it.
MILK FOR TRAVELING
In making long journeys with infants by land or water, the
feeding of the child is an important matter, and advice is often
sought by mothers who wish to make the contemplated trip with the
least possible risk. It is, of course, desirable that no change be made
in the milk commonly used, and there are means of treating the
milk and of keeping it which enable us to assure the patient of
reasonable safety. It is my custom with city children to have the
milk prepared at the Walker-Gordon Laboratory, where at a trifling
expense small ice-boxes can be obtained which contain sufhcient
space for a few days' supply of milk and which can be conveniently
carried on cars and boats. They have also larger boxes with a
capacity of twelve quarts which may be used for an ocean voyage.
The smaller box will need refilling with ice, once or twice a day,
which is usually readily secured. The larger box for ocean vovages
is packed in ice and placed in a cold-storage room of the vessel
and will not need repacking during the trip. The milk prepared
for a journey should be cooled to 45° F. as soon as it is drawn, and
kept at this temperature until it can be sterilized at a temperature
of 212° F. for twenty minutes. It then should be cooled rapidly to
at least 50° F. and kept at this point until used. These directions
can be carried out by any intelligent family. When this is done the
Tim PROPRIETARY FOODS II7
milk will be safe for use for the time required — from seven to eight
days. Of course, laboratory milk is available for comparatively
few. But the suggestion as to the making of an ice-box can be
followed in any town or village, so that a milk laboratory is not
essential. All that is required is the ice-box, the quart fruit jars
or quart milk bottles, and clean milk. Those who for any reason,
cannot avail themselves of the milk thus preserved will find in canned
condensed milk a fairly good substitute. If kept on ice and wrapped
in a sterile towel, a can of condensed milk may safely be used for three
days after opening. Formulas suited for the various months of
infancy will be found in the section on Condensed Milk (page 1 14).
THE PROPRIETARY FOODS
The foods on the market prepared for purposes of infant-feeding
are almost without number. From our knowledge of the composi-
tion of mother's milk we learn what nutritional elements and approx-
imately in what relative proportions these elements must exist in
order to supply the child with the food which nature intended him
to have. The examination of the milk of thousands of nursing
women shows that it ranges from 2.5 to 4 percent fat, 6 to 7 percent
sugar, and i to 1.5 percent proteid. These figures may be put down
as the normal limits of human milk, and they are so, simply because
the infant will thrive and grow when the nutritional elements in
approximately the above proportions are supplied to him. It is
within these limits that the food must be kept in order that there
may be normal growth and development; though, of course, wide
variations from these may be of temporary occurrence. While
the child may exist and temporarily do fairly well on a percent-
age of fat lower than 2.5, he will invariably show defective growth
if the proteid remains persistently under i percent. The chief
disadvantage in the infant foods which are used without the addition
of cow's milk, lies in the fact that they do not contain the nutritional
elements as they exist in normal breast-milk, and besides, of neces-
sity, they are all cooked foods.
In selecting a substitute for mother's milk (page 80) one point
is to be kept in mind, viz., the substitute should contain, in a readily
assimilable form, the nutritional elements in approximately the
proportions and forms in which they exist in mother's milk. All
other feeding is defective. It is not well to put too much reliance
on the analysis sometimes published by the proprietary food manu-
facturer. This type of food is decidedly weak in animal fat, for the
reason that there is no means of keeping more than a small percentage
of it in a food without its becoming rancid. When considerable
percentages are indicated in the analysis it is certain that it does not
consist of butter fat. The quantity of animal milk proteid is likewise
deficient, and what is present has been cooked, thus detracting
Il8 NUTRITION AND GROWTH
materially from its value in infant nutrition. Scurvy is not an
infrequent result of the exclusive use of these foods.
The Uses of Proprietary Dried-milk Foods. — It is to be remembered
that this type of food is condemned because of its being an unsuitable
food when used exclusively and persistently. Hysterical general
condemnation of the proprietary infant foods is an injustice.
Throughout this book, the proprietary foods will be found mentioned
from time to time and their uses dwelt upon. In constipation in
" runabout" and older children who are on a general diet, the impor-
tance of milk in the nutrition is a secondary one, and is often an
important factor in the production of constipation. In these cases
cow's milk may be replaced by one of the proprietary dried-milk
foods which has a laxative effect, with a good deal of advantage.
I sometimes employ them further in other disordered states. During
acute illness and in convalescence from illness and in certain forms
of malnutrition they are usually readily digested and may help us
over difficult places.
Proprietary Foods to Which Fresh Cow's Milk is Added. — These
are not foods in the usual acceptation of the term, and if they are
used alone independent of milk the patient will soon present a sorry
spectacle. They are sugars largely, being composed of maltose
and dextrose, which are derived from starch. Some contain a con-
siderable quantity of unconverted starch. When added to the
water and milk mixtures they furnish the soluble carbohydrates and
free starch, and thus fulfil this function in the food with as good
results as, but usually no better than, would milk-sugar and a cereal
gruel. Maltose is a laxative sugar. In case of constipation in the
bottle-fed it may replace the milk-sugar in equal quantity, and as
such may be used with decided advantage in some cases. In other
cases this change to maltose is without effect. The claim that
when added to cow's milk these proprietary foods increase the lia-
bility to scurvy is without foundation. If the milk is given uncooked,
the child will not have scurvy, regardless of the nature of the
carbohydrate; if the milk is heated to i6o° or 170° F., the child may
have scurvy regardless of the carbohydrates.
The exploiting of photographs of crowing, fat, red-cheeked
babies which are used to illustrate the supposed virtues of this or
that manufacturer's food composed principally of maltose, is not a
very high-minded procedure on the part of the manufacturer who
thus stoops to steal the credit which belongs to a cow! According
to my observation, the statement that the addition of maltose to
cow's milk facilitates its digestion is unfounded. I have tried it in
many cases, but have never been able in consequence to use a stronger
cow's-milk mixture, a higher proteid. The true test of such a meas-
ure is its use in the delicate, and in difificult feeding cases, and not in
well babies who thrive regardless of the carbohydrate employed.
CEREAL GRUELS : STARCII-FEEDING
119
The maltose preparations, then, in the sense that they may contain a
small amount of proteid and a laxative sugar, are useful and to be
recommended when such a carbohydrate is needed.
The Proprietary Beef Foods.— Numerous preparations of this
nature are on the market and there has been abundant opportunity
to test their value. Without going into a lengthy discussion as to
how and under what conditions these preparations have been used,
it is sufficient to say that as a means of nutrition in children they
play a very unimportant part. Their principal use is in illness, in
which they act as a stimulant, and to a less degree as a food. They
all make weak proteid mixtures when diluted so that the child can
take them. The possibility of supplying any great amount of
nutrition to the economy by their use is small ; occasionally, however,
they may be used to advantage. When milk is withdrawn they may
be added to the cereal gruel substitute. If there is diarrhea, great
care must be exercised, as the proprietary beef preparations as well
as beef-juice may increase it. On account of the creatinin which
they contain, they should not be given in any of the forms of nephri-
tis. Another feature which limits their use is that a child soon tires
of them. They can rarely be given more than two or three times in
twenty-four hours. Valentine's is the preparation I usually select.
It may be given in solution — one-quarter to one-half teaspoonful
to six ounces of the diluent.
CEREAL GRUELS? STARCH-FEEDING
Much discussion has taken place during the past few years as to
the use of cereals in infant-feeding.
The cereals consist of plant embryos surrounded by a mass of
highly nutritious proteids and carbohydrates in the form of starch
which nourishes the embryonic plant until it becomes rooted in the
ground. As the developing plant needs nourishment it converts
the starch into dextrin and maltose. Cereals are analogous to
eggs in that the germ is packed away in a supply of exceedingly
nutritious food which in the process of development it converts into
tissue. Almost all of the prepared infant foods are made from cereal
flours, with or without the addition of a little dried milk or sugar;
or from cereals in which the starch has been transformed into dextrin
and maltose. The proprietary meal foods which consist of baked
flours of different kinds are useful aids in infant-feeding and most
useful as milk substitutes when milk must temporarily be withheld.
The conversion of starch into dextrin by the baking process is so
slight that it may be ignored. Robinson's barley flour, Cereo Co.'s
barley flour and the other gruel flours, and Imperial Granum (baked
wheat flour) require boiling before use. They may be prepared
according to the instructions given in the formulary (page 123).
It is my custom in bottle-feeding to begin with a cereal from the
I20 NUTRITION AND GROWTH
fifth to the seventh month, by using a cereal water as a dihient of
the milk mixture. For this purpose barley or granum is usually
employed. Very often in out-patient work I begin with a cereal
diluent very early in life in order to make the food mixture more
nutritious. This method of feeding is useful when accurate modi-
fications are not possible and when the child for any reason cannot
take a milk formula as strong as its age and nutritional requirements
demand. Such cases are frequently seen in the marasmic, the
malnutrition, and the difficult feeding class. The addition of
two or three tablespoonfuls of flour to the daily food will increase
its nutritive value not a little. That boiled starch may be digested
by the youngest and most marasmic infant has been proved under
my own observ'ations.
The principal use of these flours, however, is in the gastro-enteric
diseases, where they may with safety replace the milk for considerable
periods of time. In the treatment of the acute intestinal diseases
their uses are repeatedly referred to. By eliminating milk from the
diet and giving carbohydrates, a putrefactive culture-field is removed
and a less favorable soil is furnished for the development of the
intestinal bacteria; further, there are no by-products formed to
produce intestinal toxemia or kidney irritation. Two even table-
spoonfuls of these flours to one pint of water give approximately a
food strength of 0.07 percent fat, 0.3 percent proteid, 2 percent car-
bohydrate. In order to increase the nutritive value, cane-sugar may
be added in sufficient quantity to bring the carbohydrate percentage
up to five. The addition of the sugar also makes the cereal more
palatable, and it will therefore be taken more readily by the patient.
During an invasion of scarlet fever, pneumonia, or any of the
illnesses of childhood which may be accompanied by great prostra-
tion, the usual foods, whatever their nature, should be withheld, as
the cereal gruel alone or mixed with chicken or mutton broth fur-
nishes a very satisfactory substitute. Likewise later in the disease
it is never well to give full milk while fever and prostration are
present. A useful field for the cereal gruels is as diluents of the milk
in conditions where this combination must often furnish the nutrition
for days. The use of the baked-flour gruels, with sugar or without,
as a means of nutrition should be continued only during the active
symptoms of the disease, whether it is scarlet fever or one of the
intestinal diseases. In no sense are these gruels advocated as ex-
clusive foods for infants or for growing children. I have seen many
cases where this error has been made with most disastrous results.
The Infant's Capacity for Starch Digestion Proved by Experi-
ment.— It has been claimed with more or less tenacity by different
writers that the young infant possesses no capacity for starch
digestion. During the past year a study of starch digestion in
infants of different ages was undertaken at my suggestion at the
CEREAL gruels; STARCII-FEEDIXG 12 1
New York Infant Asylum. In the first series of sixty cases, 324
stool examinations were made, for purposes of observation on ex-
clusively starch-fed children.
Boiled barley flour in the form of a gruel in amounts of from 142 to
1560 grains in twenty-four hours was given, the usual quantity being
from 400 to 500 grains. In testing for starch in the stools, the
von Jaksch iodin method was employed. In thirty-three cases
the stools were persistently negative, five examinations having been
made on five successive days; of these, eleven were under six months
of age. One, who was nineteen days old, took 142 grains of starch
daily, and the stools were negative to the two examinations made
on two successive days. One, twenty-one days old, took 225 grains
every twenty-four hours. To one, five months and twenty-six days
old, 375 grains daily wefe given. In each of these cases five examin-
ations were made, all being negative. To one five and a half
months of age 450 grains were given for three successive days.
It was then decided to increase the starch and test his digestive capac-
ity. There were accordingly given him 1 560 grains daily for two
days. The stools failed to respond to the iodin test. One was one
month and twenty-two days old. The patient was thin and he had
diarrhea. Four hundred grains were given the first day, followed
by a negative stool. Three hundred and ninety grains were given
on each of four successive days, the stools remaining negative. To
another child, one month and nineteen days old. 185 grains were given
for three days, with stools negative. The starch was then increased to
300 grains for two days, the stools still remaining negative. In seven
cases the stools were persistently positive, showing the presence
of starch in considerable amount at each examination. In twenty
cases the reactions were sometimes positive and sometimes negative.
From these examinations it was shown that of the sixty cases in
question, forty-one showed a good starch capacity and nineteen an in-
different or poor starch capacity. That some of the starch may have
undergone fermentation in the intestine is, of course, possible. How-
ever, it could not have been a factor of great consequence, for the pa-
tients did not show more than the usual bowel distention. Dextrin
was present at times in over one-half the cases, thus showing only
a partial conversion from the presence of a starch enzyme. In all
these children subjected to the test, a fair degree of nutrition was
maintained during the period of the exclusive starch diet. Several
of the starch-fed infants in which the stools were negative to iodin
were very young and very delicate. This led us to undertake a
study of the stools of infants fed exclusively on the breast, with a
view of determining, if possible, the presence of starch-digesting
enzyme or enzymes in the feces, 161 tests being made of the stools
of twenty-six children. The ages were: under two weeks, twenty-
two ; between one and two months, three ; one, the oldest child, was
122 NUTRITION AND GROWTH
two and one-half months old. The tests were conducted as follows:
A solution of starch, i : 500, was boiled for fifteen minutes. From
one to four drams of this solution were then put into a test-tube, and
to this a dilute Lugol solution was added and the tube marked for
control. To another boiled solution of starch of similar strength,
Fehling's solution was added to determine the presence of sugar,
which, of course, was absent. In another tube a portion of feces
in plain boiled water was tested for sugar and always found negative.
The observations were thus protected by three controls. In still
another tube an equal amount of a i : 500 starch solution was boiled
for fifteen minutes and a definite amount of feces by weight was
added. The contents were then thoroughly shaken and placed in a
water-bath, which was maintained at a temperature of 100° F. for
one-half hour. The solution was then tested for sugar with Fehling's
solution. In every case the presence of sugar was indicated, thus
proving the presence of something in the feces which transformed
the starch into maltose. The observ^ations agree with those of
von Jaksch, who proved a starch-converting ferment in twenty-eight
out of thirty cases, and with those of Moro, who proved the same
thing in thirty-eight out of forty cases.
It was found that the converting capacity of the feces for starch
was in the proportion of one grain of feces to about one-twentieth
grain of starch, this amount being required for the complete con-
version of the starch into sugar. In one case there was a capacity
of but one-sixtieth grain of starch to one grain of feces. In three,
one grain of feces converted one-tenth grain of starch. When
stronger starch solutions were used, there was a response both with
the Lugol and Fehling solutions, showing a partial conversion. In
three, the examinations began on the day of birth and were continued
for several days, four examinations being made in each case. Six
were commenced on the second day and continued for four days.
One premature baby (eight months) which lived six da^^s and
weighed four pounds four ounces showed a power of conversion of one
grain of feces to one-thirty-second grain of starch.
Excluding bacteria of feces and the ptyalin of the saliva, it would
seem that the succus entericus and the pancreatic juice were respon-
sible for the very active diastatic ferment.
Zweifel and Korwin were unable to extract a diastatic enzyme
from the pancreas, in infants under three weeks old, and concluded
therefore that none existed. Their methods cannot be accepted
at the present time as establishing this point, as the glands were
macerated and placed in distilled water, in some instances for only
one-half hour, and then mixed with a strong starch solution. Moro
followed along the lines laid down by Zweifel by using distilled
water, though the maceration was continued for a much longer
time, and in ten infants under three months of age proved a diastase
FOOD FORMULAS I 23
in the pancreatic extract in seven. In two of these the infants
died at birth. One lived fourteen days. Four were between one
and three months of age. We now know that much stronger ex-
tracts of the pancreas are to be obtained when the organ is cut into
small pieces, ground with sand in a mortar, and macerated in a solu-
tion of 15 percent alcohol or 40 percent glycerin. Furthermore,
it is not logical to compare with a dead organ the active functionating
pancreas of a living child under the stimulating influence of food in
the intestine. Our own observations as to the elaboration of pan-
creatic extract and the succus entericus have not been carried far
enough to warrant any authoritative statement based on the findings ;
but the claim that the diastase is furnished by the mother's milk is
negatived to a great extent by the fact that the feces extract from
meconium stools was as active before breast-feeding as later.
It will be seen from the foregoing that the majority of infants
of tender age are able to digest starch. With not every infant is
this possible, and, according to this report, starchy foods thus resem-
ble every other substitute feeding. Not every infant by any means
can take cow's milk or asses' milk or goat's milk; but that starchy
foods may be added with benefit to infant milk foods in a great
majority of the cases, and that they may be used with benefit as a
substitute for these foods in illness, is established beyond all question,
both experimentally and clinically.
FOOD FORMULAS
Beef-juice. — Take a round steak, cut into pieces the size of a
horse-chestnut, place in a buttered pan in a hot oven, and bake for
fifteen minutes ; remove from the pan and press out the blood ; add
salt to the taste.
Beef, Mutton, and Chicken Broth. — Take one pound of meat
free from fat, cook for three hours in one quart of water, adding
water from time to time, so that when the cooking is completed
there will be one quart of broth. When the broth is cool, remove the
fat, strain, and add salt to the taste.
Scraped Beef.— Broil round steak slightly over a brisk fire.
Split the steak and scrape out the pulp, using a dull knife.
Egg-water. — The white of one egg, thoroughly beaten in one
pint of cold, boiled water; strain; add salt to the taste.
Oatmeal Jelly.— Oatmeal, four ounces; water, one pint; boil for
three hours in a double boiler, water being added, so that when
the cooking is completed a thin paste will be formed. This while
hot is forced through a colander to remove the coarser particles.
When cold, a semisolid mass will be formed.
Wheat Jelly and Barley Jelly.— Wheat jelly and barley jelly
are made in the same way as oatmeal jelly, using cracked wheat or
barley grains.
Barley-water (No. i).— Robinson's barley flour or Cereo Co.'s
124
NUTRITION AND GROWTH
barley flour, one rounded tablespoonful ; water, one pint. Boil
thirty minutes ; strain ; add water to make one pint.
In making Barley-water No. 2, two tablespoonfuls of the flour
are used.
Rice-water (No. i). — Rice, one tablespoonful; water, one pint;
boil three hours, adding water from time to time, so that there is
one pint of rice-water at the end of the three hours.
In making Rice-water No. 2, two tablespoonfuls of rice are used.
Dextrinized Barley-water. — Robinson's barley flour or Cereo
barley flour, three tablespoonfuls; water, one pint; boil twenty
minutes; add water to make a pint. When lukewarm (100° F.),
add one teaspoonful of Cereo ; strain ; this changes the starch into
dextrinized maltose.
Oatmeal-water (No. i). — Oatmeal, one tablespoonful; water,
one pint; cook three hours and add water to make one pint.
In making Oatmeal- water No. 2, two tablespoonfuls of oatmeal
are used.
Imperial Granum-water (No. i). — Imperial Granum, one table-
spoonful; water, one pint; cook three hours and add water to make
one pint.
In making Granum-water No. 2, two tablespoonfuls of Granum
are used.
Percentage Gruel Flours. — There has recently been put on the
market in tin boxes, the covers of which are used as measures, a
series of flours, especially made for preparing cereal gruels and
jellies of known percentage composition. On the labels are given
only the cooking directions for preparing plain or dextrinized gruels,
and their composition when different quantities of flour are used
as follows :
APPROXIMATE COMPOSITION OF GRUELS MADE FROM CEREO CO.'S
GRUEL FLOURS.
Barley.
Legume.i
Oat.
Wheat.
'S
hi
i
ll
il
1
ii
<Z 2
U l^
d-a
2
cS-o
,"!-a
£
'-'^
£
"^^
^.s-
£
U >•
i^ ounce flour to quart of
water
O.I2f'.
o.6ofc 0
igf.
■ o.53r* 0
12^
o.e&fc 0
laf.
0.62f.
% ounce flour to quart of
water
0.24^
20^ 0
39f«
1.06^ 0
2Af>
1.20^ 0
20^
1.25fi
%. ounce flour to quart of
water
0.36^*
9^c 0
58/.
159^ 0
z(4
i.Sof. 0
3of»
i.m
I ounce flour to quart of
water
0.48^,
40^ 0
78;^
2.12!4 0
48r.
2.40;^ 0
4o?J
2.50^
2 ounces flour to quart of
water
0.96^
80^ I
56fi
4.24fe 0
9(4
4.So!i 0
Soft
s.oor*
3 ounces flour to quart of
water
i.445«
20^ 2
34''*
6.36^ I
44!^
■J.2C4 I
20fc
7.50;^
4 ounces flour to quart of
^^ ^
1.99^
6c4 3
12^
8.40^ 1
92f,
9.6054 I
eoi,
lO.OOfe
Made from equal parts of peas, beans, and lentils.
HABITUAL LOSS OF APPETITE 1 25
Whey. — Put one pint of fresh milk into a saucepan and heat it
lukewarm, not over 100° F. ; then add two (2) teaspoonfuls of Fair-
child's essence of pepsin and stir just enough to mix. Let it stand
until firmly jellied, then beat with a fork until it is finely divided;
strain, and the whey, the liquid part, is ready for use.
Junket. — To one pint of fresh milk add two teaspoonfuls of
sugar. Allow it to stand over a fire until the temperature is 100° F. ;
then add vanilla as a flavoring and allow it to stand until the curd
is set, when it should be placed upon ice.
HABITUAL LOSS OF APPETITE
The growing child, like the adult, not only requires sufficient
nourishment to sustain life, but, in addition to this, an extra amount
to supply the demands of growth. Proportionate to their size,
therefore, all growing animals require more food than do those that
have reached maturity. The young child is naturally such a very
hungry animal that ample feeding is absolutely essential. Therefore,
when there is a habitual loss of appetite so that the child's entire
life may be unfavorably influenced, we must realize the fact that
the condition is abnormal and strive to discover the cause and
apply the remedy.
Physicians are often consulted by parents whose children are
suffering temporarily or persistently from loss of appetite — a con-
dition usually associated with secondary anemia and asthenia.
The child apparently is not ill, he may be active and playful, but
he tires easily. The sleep ordinarily is sound and refreshing but the
child must be coaxed to eat. Oftentimes he will take food only
when his attention is diverted by a story or a toy. He usually eats
for the entire family, taking a mouthful each for father and mother,
for the coachman, and for the cook! Three or four times a day,
depending upon the number of meals, this coaxing, entertaining
process has to be gone through with. Occasionally in children with
habitually poor appetites for food in general there will be a history
of excessive milk-drinking. From three to five glasses of milk may
be taken daily and all other food refused. When milk forms the
principal or only article of nourishment after the eighteenth month,
children will invariably show evidences of malnutrition. They are
apt to be pale and sallow, with flabby muscles. The most frequent
cause of loss or lack of appetite is too frequent feeding. It is not
at all uncommon to see children from two to four years of age who
are being fed six or seven times in twenty-four hours, the argument
of the parents being that: "The child takes so little food, he ought
to take it oftener." With increasing age, more and stronger food
is required at less frequent intervals. In other cases children may
not get their regular feedings at such frequent interv^als, but are
generously supplied between meals with candy, cake, crackers, and
126 NUTRITION AND GROWTH
fruits. Unsuitable food may be the cause of a habitually poor appe-
tite. Children of tender age who are regularly fed from the adult
table with heavy adult food, oftentimes improperly cooked, soon
suffer from loss of appetite. Children who are poor eaters usually
have the associated ailment, constipation. Too close confinement
indoors is not infrequently associated with, if not a direct cause of,
lack of appetite. Children who are kept uninterruptedly in the
house for weeks at a time invariably have poor appetites.
Treatment. — In order to emphasize a point in teaching, when treat-
ment is under consideration, I have sometimes found it useful to state,
first, what not to do. Do not give these children drugs as a means of
inducing an appetite until all other means have failed. The only
medication that should be permitted is some simple laxative. There
must be one evacuation of the bowels daily. The aromatic fluid
extract of cascara sagrada, from one to two drams, given daily at
bedtime, or from three to five ounces of the citrate of magnesia
given before breakfast, ordinarily answers well.
Fresh Air. — Every "runabout" child should spend at least five
hours daily in the open air, regardless of the season of the year.
During very inclement weather in winter indoor airing (see page
36) is a most satisfactory substitute.
Diet. — An important step in the treatment is in the regulation of
the feeding hours. A child from twelve to fifteen months old re-
quires five feedings daily (see Dietary, page 128). Ordinarily, for
" runabout" children from the fifteenth to the twenty-fourth month,
four meals daily are necessary. After the second year, only three
meals should be given. All feedings should be given at a definite
time each day, which should never be deviated from. Nothing what-
ever except water should be allowed between meals. My next step,
in case these regulations fail, is to place the child temporarily on a
markedly reduced diet. No solid food, such as meat, eggs, bread-
stuffs, vegetables, or fruits, is allowed. The mother must be given
the directions both orally and in writing. Milk, gruels, and broths
should comprise the nourishment.
If the case is one of milk habit, then the milk must be entirely
cut off, and broth, thin gruel, dry bread, or zwieback substituted.
The mother is instructed to return with the child in two days. In
the great majority of instances the report after forty-eight hours is
that the child is ravenously hungry. When such is the case freer
feeding is allowed, but under the same strict observance of feeding
inter\'als, with absolutely no feeding between meals. It is extremely
rare to meet a case of habitual loss of appetite which will not respond
to this simple method of treatment.
Change of Climate. — Occasionally a child is brought for treatment
who fails to show the least evidence of disease and yet will not re-
spond to proper dietetic and hygienic measures. For such, a change
COMMON ERRORS IN FEEDING 1 27
of climate in addition to proper methods of feeding has been found
advisable. A change from the city to the country; or from the
country inland to the seashore, has been followed by a decided
improvement. When such changes are impossible, or when proper
dietetic regulations are impracticable, as with our dispensary patients,
medication may be of service.
Tonics. — In my experience the best medicinal means of improving
the appetite is a solution of citrate of iron and quinin in sherry wine,
one grain of the citrate of iron and quinin being dissolved in one-half
dram of sherry wine and given, well diluted, before meals. This
dosage will answer for children over eighteen months of age. For
younger children, one-half grain of the citrate of iron and quinin in
one-half dram of sherry wine, well diluted, may be given. If this
is not successful one minim of dilute hydrochloric acid, one-half
minim of the tincture of nux vomica, and two teaspoonfuls of water
may be given before meals to children over fifteen months and
under two years of age. After the second year two minims of the
dilute hydrochloric acid and one minim of nux vomica before meals
in three teaspoonfuls of water may be given.
There remain also to be considered under this head not a few
children who habitually suffer from poor appetite who are below the
average in every respect. This type of child is considered in detail
under the heading of The Care of the Delicate Child (page 142).
COMMON ERRORS IN FEEDING
In the bottle-fed the most frequent error is overfeeding, or a
stronger mixture is given than the child is able to digest. Particu-
larly is this apt to be the case at the commencement of bottle-feeding.
The amount is usually too large and the intervals between the
feedings are almost invariably too short. Children of the same
age cannot all be fed alike. Artificially fed babies of equal health
and vigor, but of considerably varied size and weight, will require
food of approximately the same strength and the same intervals
between feedings ; but the larger the child, the greater the quantity
of food required. Thus, the quantity given at one feeding for a
child weighing thirteen pounds at the sixth month will not be suffi-
cient for a child of the same age weighing sixteen pounds.
The quantity of food for each feeding for an average baby
weighing fifteen pounds at six months is about six ounces, and this
quantity should be diminished one-half ounce for every pound under
this weight until the total quantitv is reduced to four ounces ; and
for every pound over fifteen, one-half ounce should be added to each
feeding until the total is increased to nine ounces. The number of
feedings in twenty-four hours should be the same for all young^
children of the same age. In the table of food formulas given on
page 92, only the average child of average weight is considered.
128 NUTRITION AND GROWTH
AGE OF CHILD, SIX MONTHS.
Weight of Child. Quantity for Each Feeding.
1 1 pounds 4 ounces
1 2 pounds • 4^ ounces
13 pounds 5 ounces
14 pounds 5-V ounces
1 5 pounds 6 ounces
16 pounds 6 f ounces
1 7 pounds 7 ounces
1 8 pounds 7 V ounces
1 9 pounds 8 ounces
20 pounds 8^ ounces
2 1 pounds 9 ounces
Keeping the child on an exclusive milk diet until he is twelve
months of age, or older, is a not infrequent error. As a rule, starch in
some form may be added to the food at the seventh month, and should
always be added as early as the ninth month. The giving of food
other than well-cooked cereals and milk before the twelfth month is a
mistake made in many households, and a common error from the
twelfth month to the third year is to allow the child's diet to con-
sist largely of milk and insufficiently cooked cereals. Crackers and
milk, bread and milk, with cake and fancy crackers, often constitute
the only articles of diet during this very important period of growth.
The fact that a high proteid food is as necessary for proper develop-
ment now as for the bottle age, is overlooked. During early infancy,
milk answered well, but it is not sufficient for the demands of older
childhood. Milk, eggs, meat, and cereals, such as oatmeal, rich in
proteid, are absolutely necessary to normal growth.
Irregularity in feeding is another frequent error. The child
should have his meals "on the minute," at the same time every day.
The lack of observance of this rule will surely result in loss of appetite
and indigestion. Indiscriminate eating between meals, whether
bread and butter, or pastry, or confectionery, if persistently practised,
will surely be followed by indigestion and malnutrition.
Forcing or coaxing a child to eat is a practice always to be
avoided. If suitable food is given at definite well-ordered intervals,
a normal child will be hungry at those intervals. If he does not eat,
something is wrong, and it is our duty to discover the cause of his
loss of appetite.
DIET FROM THE FIRST TO THE SIXTH YEAR
At the completion of the twelfth month the average well-regulated
breast baby should be weaned, and other nourishment given. If
bottle-fed, he should receive more than the milk and cereals which
are given to most children. The food suitable for the second year
of life, and the method of its preparation and administration, are
subjects upon which the masses are most profoundly ignorant. A
few children at this period of life are underfed, but the great majority
are overfed, the food being whollv unsuitable, wretchedly cooked, and
DIET FROM THE FIRST TO THE SIXTH YEAR
129
carelessly given at improper intervals. vSummer diarrhea finds its
greatest number of victims among such children.
The Second Summer. — The dreaded "second summer" robs many
homes because of ignorant or careless parents. The second summer,
properly managed, is hardly more dangerous than any other summer
during the early years of a child's life. It is almost a universal
custom, when a child is weaned or given something other than a
milk diet, to allow him "tastes" from the table. Very often these
"tastes" comprise the entire dietary of the adult. Milk is often the
only suitable article of diet that is given. Afterward not only is
the other food selected unsuitable, but it is given irregularly, and
supplemented by crackers kept on hand for use between meab.
During the hot months the gastro-enteric tract is less able than at
other times to bear such abuse, and the child becomes ill.
Feeding After the First Year. — Usually, when the twelfth month
is completed, I give the mother a diet schedule, with instructions to
begin gradually with the articles allowed in order to test the child's
ability to digest them. Every new article of food should be care-
fully prepared and given, at first, in very small quantities. All meals
should be given regularly, with nothing but water between. With
many children this expansion of the diet list is attended with con-
siderable difficulty. They are thoroughly satisfied with the milk,
and refuse all other nourishment. In such cases time and patience
are necessary at the feeding-time. The more solid articles of diet
should first be given, and the milk kept in the background. Among
the underfed seen at this period of life are those who were nursed
too long, or those who were kept for too long a time upon an exclusive
milk diet. A great majority of the cases of malnutrition of the
second year are seen in the exclusively milk-fed. They are pale,
soft, flabby, badly nourished children.
The following is a diet schedule which I have emploved for
several years. Each mother is instructed to select, from the articles
of food allowed, a suitable meal:
From ike twelfth to the fifteenth month: five meals daily.
7 A. M. Oatmeal, barley or wheat jelly, one to two tablespoon-
fuls, in eight ounces of milk. (The jelly is made by cooking the
cereal used for three hours the day laefore it is wanted and then
straining through a colander.)
9 A. M. The juice of an orange.
II A. M. vScraped rare beef, mixed with an equal quantity of
bread-crumbs, moistened with beef-juice, one to three teaspoonfuls.
Or a soft-boiled egg mixed with stale bread-crumbs, a piece of zwie-
back, and a half-pint of milk.
(Scraped beef is best obtained from round steak, cut thick and
hroiled over a brisk fire sufficiently to sear the outside. The steak
9
130 NUTRITION AND GROWTH
is then split with a sharp knife and the pulp scraped from the
fiber.)
3 p. M. Beef, chicken, or mutton broth with stale bread broken
into it.' Six ounces of milk, if wanted.
6 P. M. Two tablespoonfuls of cereal jelly in eight ounces of
milk; a piece of zwieback.
9.30 p. M. A tablespoonful of cereal jelly in eight ounces of milk.
From the fifteentli to the eighteenth mo)ith: four meals daily.
7 A. M. Oatmeal, barley, or wheat jelly, one to two tablespoon-
fuls in eight ounces of milk. (The jelly is ,to be made by cooking
the cereal used for three hours, and straining through a colander.)
9 A. M. The juice of one orange.
II A. M. A soft-boiled Qgg mixed with stale bread-crumbs or
one tablespoonful of scraped beef mixed with stale bread-crumbs
and moistened with beef -juice. A drink of milk; zwieback or bran
biscuit, or a crust of bread.
3 p. M. Mutton, chicken, or beef broth, with stale bread
broken into it. Custard, cornstarch, or plain rice pudding, stewed
prunes, baked apple, or apple sauce.
6 P. M. Two or three tablespoonfuls of cereal jelly with eight
to ten ounces of milk. Zwieback or stale bread with butter.
From the eighteenth to the twenty-fourth month: four meals daily.
7 A. M. A soft-boiled egg every two or three days, farina
(cooked one hour), hominy or oatmeal (each cooked three hours),
with equal parts of milk and cream and a little sugar. A drink of
milk, bran biscuit and butter, or stale bread and butter.
9 A. M. The juice of one orange.
II A.M. Rare beef, minced or scraped, the heart of a lamb
chop finely cut, spinach, asparagus tops, strained stewed tomatoes,
mashed cauliflower, baked apple or apple sauce. A drink of milk,
stale bread and butter.
After the twenty-first month, baked potato and well-cooked string-
beans may be given.
3 p. M. Chicken, beef, or mutton broth, with stale bread broken
into it, custard, cornstarch, or plain rice pudding, stewed prunes,
a drink of milk, bran biscuit and butter, or stale bread and butter.
6 p. M. Rice (cooked three hours) and milk, hominy (cooked
three hours) and milk, farina (cooked one hour) and milk, or stale
bread and milk.
From the second to the third year: three meals daily.
Breakfast: 7 to 8 o'clock. Wheatena, oatmeal, hominy, cracked
wheat (each cooked three hours), with equal parts of milk and
cream and a little sugar.
DIET FROM THE FIRST TO THE SIXTH YEAR 131
A soft-boiled egg or a lamb chop, stale bread and butter, bran
biscuit and butter; a drink of milk.
At ten o'clock the juice of one orange may be given.
Dinner: 12 o'clock. Strained soups and broths, rare steak,
rare roast beef, poultry, fish, baked potato, peas, string beans,
mashed cauliflower, strained stewed tomatoes, spinach, asparagus
tips, bread and butter; a glass of milk. For dessert: Plain rice
pudding, plain bread pudding, stewed prunes, baked or stewed apple,
junket, custard or cornstarch.
Supper: 5.30 to 6 o'clock. Rice and milk, farina and milk,
bread and milk, bread and butter, or bran biscuit and butter.
Twice a week, custard or cornstarch may be given or a tablespoonful
of plain vanilla ice-cream.
As a rule, three meals answer best at this period. With three meals
a child has a better appetite and much better digestion, and conse-
quently thrives far better than one whose stomach is kept constantly
at work. Some children, however, will require a luncheon at 3 or
3.30 p. M., and will not do well without it. This is apt to be the case
with delicate children, particularly those under two and one-half
years of age. If food is necessary at this hour, a glass of milk and a
graham biscuit, or a cup of broth and zwieback will answer every
purpose. Instead of the afternoon meal, the child may relish a
scraped raw apple or a pear. The fruit at this time is particularly
to be advised if there is constipation. Children recovering from
serious illness will require more frequent feeding.
From the third to the sixth year.
Breakfast: Cracked wheat, wheatena, hominy, oatmeal (each
cooked three hours). These may be served with equal parts of
milk and cream and a little sugar.
A soft-boiled Qgg, omelet, scrambled Qgg, chop, bread and butter,
bran biscuit and butter, a glass of milk, one orange, one-half dozen
stewed prunes.
Dinner: Plain soups, rare roast beef, beefsteak, poultry, fish,
potatoes stewed with milk or baked. Peas, beans, strained stewed
tomatoes, mashed cauliflower, spinach, asparagus tips, bread and
butter, a cup of milk. For dessert: Rice pudding, plain bread
pudding, custard, tapioca pudding, stewed prunes, stewed apples,
baked apples with cream, raw apples, pears and cherries.
Supper: Rice and milk, farina and milk bread and milk, scram-
bled Cigg twice a week, custard or cornstarch, each once a week,
ice-cream once a week, bread and butter, a glass of milk.
When the child has eggs for breakfast, they should not be re-
peated in any form for supper. Red meat should be given but once
a day. W^hen the child has a chop for breakfast, he should have
poultry or fish for dinner. At this age of great activity and rapid
132 NUTRITION AND GROWTH
growth, the child will demand food between dinner and supper.
Carefully selected fruit, such as an apple, a pear, or a peach, may be
given at this time, supplemented by a graham cracker or two, or by
stale bread and butter, if it is found that their use does not interfere
with the evening meal.
DIET AFTER THE SIXTH YEAR
When the normal child has passed the sixth year the diet may
be considerably expanded, approximating to that of the adult in
variety; certain restrictions, however, are to be borne in mind.
Fried foods should not be given, highly seasoned dishes, such as pie,
rich puddings, gravies, and sauces, are to be avoided. Salads with
plain dressing may now be given. Wine and beer, coffee, and tea
should never be given to children as a beverage. A point to be
kept in mind in feeding children of this age, as well as those who
are younger, is the proper cooking of vegetables. Everything in
the line of green vegetables should be cooked until it can readily be
mashed with a fork.
HOW THE CHILD SHOULD BE FED
In the foregoing articles on feeding I have endeavored to explain
the nature of the food required by the growing child, and the inter-
vals at which food should be given. This, however, does not entirely
cover the subject. A child should never dine with adults until he
can have adult diet, if the circumstances of the family permit him
to dine alone or with other children. It is a refinement of cruelty
to expect a hungry child of tender age to sit at the table, see and
smell the fragrant dishes, and be forced to content himself without
complaint with his restricted fare. I recall this custom as a cause of
many tears, disputes, and fistic encounters with attendants, which
formed no small part of the daily routine of my own early life.
In feeding, the spoon or fork must come in contact only with the
food and the child's mouth. If it falls to the floor by accident it
should be dipped into boiling water before using it. Under no
circumstances should a feeding utensil be allowed to come in contact
with the lips of the nurse or mother. Time and again I have seen
mothers and nurses sip or swallow the first teaspoonful of the food
which is to be given, to determine if it is of the proper temperature,
using the spoon to feed the child immediately thereafter. At other
times, when the food is not particularly attractive to the child, she
will place the spoon in her own mouth as though intending to take
it herself. Or she will remove from the spoon, with her own lips
adhering particles of food. There are few more reprehensible prac-
tices than the foregoing, and if parents knew the dangers to which
their children were thus subjected they would not for one instant
tolerate them. Any one of the many forms of pathogenic bacteria
DIET DURING ILLNKSS 1 33
may thus be readily transferred to the mouth of the child. It
is unquestionably a means of infection with tuberculosis, diphtheria,
and syphilis". The germs of tuberculosis and diphtheria are fre-
quently found in the mouths of perfectly healthy adults. They
cause no symptoms of disease because of the normal power of resis-
tance of such adults. The resisting powers of the child, however,
to these microorganisms are very slight, and when these germs are
carried to the delicate mucous membrane of the infant's mouth and
throat they thrive actively, the child develops diphtheria or tuber-
culosis, and the family grieves and wonders how the child could ever
have contracted the disease.
DIET DURING ILLNESS
The digestive capacity of every child is diminished during illness,
depending largely upon the age of the child and the severity of the
disease. The younger the child, the greater the incapacity. This
is fairly constant with all the ailments of childhood, including, of
course, those which directly afifect the gastro-enteric tract.
Reduction in Food Strength. — In a moderately severe bronchitis,
wath a degree or two of fever, the digestive capacity is slightl}^ dimin-
ished and a 25 percent reduction in the strength of the food wdll
answer. During the critical stage of a lobar pneumonia the digestive
powers are held in abeyance and predigested foods and alcohol must
sustain the patient. During an attack of measles, scarlet fever, bron-
chopneumonia, or diphtheria in bottle-fed infants, at the height of the
disease, it is my custom to reduce the strength of the food one-half by
the addition of water, to make up for the quantity removed. For ail-
ments of lesser severity, such as bronchitis, with a temperature of 100°
to 101° F., or chicken-pox, or mild measles, I reduce the strength of the
food from one-fourth to one-third. In any mild ailment or injury
which confines a child to its bed, the food strength should be cut
down, for inactivity as well as disease lessens the digestive capacity.
Among nurslings and the bottle-fed these precautions are partic-
ularl}^ necessary. A child with fever is apt to be thirsty and to take
more food than in health. This is frequently the case in summer
diarrhea. In order to avoid this taking of too much food, I not only
order the milk to be diluted for the bottle-fed, but I instruct the
mothers of nurslings to give a drink of water immediately before each
nursing and between nursings, and then to allow the child to nurse
only one-half or two-thirds the usual time. For the bottle-fed,
one-half to two-thirds of the contents of each bottle is removed and
the quantity replaced by boiled water, so that the amount of fluid
given remains the same.
If a child is a "runabout," over two years of age, he is given broths
and thin gruel — one-half milk and one-half gruel. By carefully watch-
ing the stools, thus fitting the food to the child's capacity, we will
134 NUTRITION AND GROWTH
avoid grave intestinal complications which, during the summer, often
prove to be more serious than the original ailment. In the acute gastro-
enteric troubles, and in typhoid fever, all milk must be discontinued.
The dietetic management of the acute intestinal diseases and
typhoid fever is referred to in detail under their respective headings.
The Art of Feeding in Illness. — Not only is food oftentimes taken
in insufficient quantity in illness, but in many cases it is absolutely
refused. In other cases, during coma and asthenic states, swallowing
is impossible. In delirium and in conditions of collapse nourish-
ment must be given, and when this is impossible by the natural
method, we have, as temporary substitutes, gavage, oil inunctions,
and rectal feeding — all referred to elsewhere.
Forcing the child to take nourishment by the mouth is rarely
necessary. Coaxing and bribing ordinarily succeed far better.
For a child from three to five years of age a bright new penny pos-
sesses much persuasive power. The child will usually take its food
better from those to whom it is accustomed, like the mother or
nursery maid. The trained nurse should understand that while
unacquainted with the patient, the simpler requirements of the
child are to be looked after by others to whom the patient is accus-
tomed.
The nourishment should be as palatable as possible and serv^ed
in bowls, cups, or plates that are attractive to the patient, be-
cause of color, pictures, or peculiarities of shape. Junket, flavored
with vanilla, serv^ed cold is a favorite food for sick children of the
"runabout" age. Frozen custard and home-made ice-cream, made
with one-third cream and two-thirds milk, will usually be well taken.
Toast, dry bread, and crackers made in peculiar shapes are attractive
to the child. In not a few cases I have succeeded in feeding satis-
factorily children two or three years old, when several other schemes
had failed, by allowing the temporary return to the bottle, from
which they had been weaned for a year or so.
In these difficult feeding cases the child's peculiarities and wishes
must be studied. Children in illness require water. Oftentimes
they take it in insufficient quantities. Those who refuse plain
water will often take ginger ale, sarsaparilla, or vichy. In the event
of these drinks being well taken, they may be given freely. In the
acute infectious diseases, which include pneumonia, free water-
drinking is a therapeutic measure of no mean value.
GAVAGE
Gavage, or forced feeding, is the introduction of nourishment
into a child's stomach by means of a tube (Fig. i6). The tubes
are to be obtained at the instrument-makers and are known as
"stomach-tubes for children," or the physician can make one himself
at a small cost. All that is required is a soft-rubber catheter,
GAVAGE
135
American No. 12, a one-eighth inch glass tube two inches long, two
feet of one-quarter inch plain rubber tubing, and a small glass funnel.
An extra opening should be cut in the catheter about one-half inch
from the original one. This allows a more rapid introduction of
the nourishment. The opening can very easily be made with a
small pair of curved scissors.
In Obstinate Vomiting. — Gavage, or forced feeding, will be found
useful in three types of cases. First, as a means of feeding in obsti-
nate vomiting. vSeveral years ago, when the writer was resident
physician at the New York
Infant Asylum, a series of
observations were made on
cases of persistent vomiting
which could not be con-
trolled by stomach-washing
or the ordinary means of
treatment. It was found
that patients who could not
retain a teaspoonful of
water when administered
by a spoon or a bottle would
retain from one-half ounce
to one ounce of water when
given through a tube. The
same child who vomited
one teaspoonful of milk
or other food would re-
tain this amount and a
great deal more when the
food was given by the
tube. This discovery led
to more extended observa-
tions. Twenty cases of
persistent vomiting in all
were treated in this way,
of which eighteen were re-
lieved. This series of ob-
servations was the first made relating to the use of gavage or forced
feeding in persistent vomiting.^
The tube which is to be passed into the stomach should never be
oiled, but merely dipped into the solution that is to be used. It is
then passed in rapidly with the funnel empty and the nourishment
immediately poured into the funnel. When the food has passed
into the stomach, the tube should be compressed and quickly with-
'Kerley: "Gavage in Persistent Vomiting in Infants," Archives of Pediat-
rics, Feb.. 1901.
Fig. 16.— Stomach-tube.
136
NUTRITION AND GROWTH
drawn, as some of the liquid will be retained in the tube if it is
withdrawn slowly. If this is done without compressing the tube,
an escape of food into the larynx may take place during the with-
drawal of the tube and cause choking, coughing, and perhaps vomit-
ing. The food selected should be thin dextrinized gruels, or broths
and gruels combined, which have answered well in some cases.
When used for the obstinate vomiting cases, it is well to use gavage
only once every four or six hours, with from one-third to one-half
Fig. 17.— Feeding by Gavage.
the quantity of food given in health. In a severe illness, such as
diphtheria, pneumonia, and the grave intestinal diseases, gavage
may save the life of the patient. Not infrequently, in such cases,
insufficient nourishment is taken to support life. Rectal feeding
is usually of value only for a day or two, as children soon become
intolerant of it. In such circumstances, gavage may be employed
advantageouslv for several davs at a time. In fact, it is the only way
by which the child can be properly nourished.
gavage; 137
The position of llic child for gavage may be the same as for
stomach-washing, or the child may rest on his back (I'ig. 17). It is
well to clear out the stomach with warm water before each feeding.
In children without teeth the bare index-finger is all that is necessary
to keep the mouth open. In children with teeth the Denhard gag
of the O'Dwyer intubation set (page 311) should be used. Pre-
digested cereal foods, completely peptonized milk, and stimulants
well diluted may be given. Usually these patients badly need water.
If there is no tendency to vomiting, a large quantity of water may
be given with the nourishment selected, so that they may get as
much liquid as they are accustomed to in health. Gavage is also
most useful in cases of extreme malnutrition and exhaustion or in
those under alcohol or opium narcosis. Infants suffering from an
extreme degree of malnutrition and exhaustion are often admitted
into a hospital ; and occasionally they are seen in private practice.
The children are so reduced in strength that not enough energy
remains for the taking of nourishment. In these cases gavage is
distinctly a life-saving measure. The food should be predigested
cereals, peptonized milk, or one of the various peptone preparations,
given in quantities suitable to the age of the child. For a child four
months of age, from two to four ounces of peptonized milk may be
given every two hours. Before the next feeding it is well to intro-
duce a few ounces of water and withdraw it to see if the food has been
properly digested. By this means of feeding there will be noticed,
if the vitality is not at too low an ebb at the commencement, a daily-
increase in strength and vigor, which proves that the powders of
assimilation persist after the desire for food or the child's ability to
swallow it has passed. This proves that we must never regard such
a case as hopeless so long as the child is breathing. Time and again,
after a few days' feeding in this way, the child will take the food from
the bottle or spoon. Breast-milk, if it can be obtained, may be
given by gavage as successfully as can predigested cow's milk.
The malted foods on the market have been used temporarily with
advantage, for, while deficient in nutritive value for the well, they
afford sufficient nourishment for temporary use in the very ill, and
are easy of digestion.
Illustrative Case. — In a recent case seen in consultation, the pa-
tient, three months old, was almost moribund, as the result of ex-
treme malnutrition. The temperature ranged from 94° F. to 96° F.
for several days. No food could be taken. A wet-nurse was secured,
but the child would not nurse. He was pale, apathetic, and too w^eak
to cry. The wet-nurse's milk was drawn from the breast and spoon-
feeding attempted, but swallow^ing was impossible. One and one-half
ounces of breast-milk were fed bv gavage, but this proved too strong,
and the child promptly vomited it. It was then diluted one-half
with weak barley-water. At first one ounce was given at a feeding,.
138 NUTRITION AND GROWTH
which was gradually increased to two ounces, all being retained and
digested. In a week the child was able to nurse, and made a com-
plete recovery, weighing, when seven months of age, fourteen pounds.
At the time gavage was commenced, it weighed but five pounds.
SUBSTITUTES FOR STOMACH-FEEDING
In the management of the diseases of children conditions arise
from time to time which necessitate the nourishment of the patient
by channels other than the stomach. In persistent vomiting, when
there is an acute involvement of the stomach, as in an acute gastro-
enteric infection, or when the vomiting is due to some more
remote cause, as in meningitis or nephritis, or where the attack is
one of cyclic vomiting; and, in short, whatever be the cause, the
patient must receive water and food in order to sustain the system
until the exciting factor is removed.
Nutrition by means other than the stomach may be necessary
in retropharyngeal adenitis or abscess, in stricture of the esophagus,
in diphtheria, in the exanthemata, and in pneumonia during the
course of active delirium. A substitute for stomach-feeding is often
useful in marasmus, in the generally delicate, and in those with
reduced assimilative powers. Various means of substitute feeding
have been attempted from time to time. Nutritive suppositories
have been advocated and proved failures, perhaps because of our
inabilitv to place them sufficiently high in the bowel. Placed in the
rectum, they excite peristalsis and are expelled.
Hypodermic Feeding. — Hypodermic feeding, and the introduction
of food into the circulation, in children are unsafe and impracticable.
Feeding by Inunction. — Feeding by means of oil inunctions, by
active friction, or by the more passive means of wrapping the
child in oil-soaked cotton and allowing him to rest in it, is thought
by many to be effective, in spite of the fact that the skin is an organ
of excretion, and that its powers of absorption are very slight. I
am convinced that, for infants and young children, the inunctions of
properly selected oils possess distinct nutritive value, more benefit
being derived by the patient than can be attributed to the lubrication
of the skin and the massage. The rubbing of mercurial ointment into
the skin is one of the most familiar means of introducing mercury
into the circulation. No one will dispute the efficacy of this form
of treatment. Fat inunctions are useful in marantic infants, and in
delicate "runabouts" with low, fat-digestive capacity. In chronic
diseases also, such as tuberculosis, syphilis, and rheumatism, oil
inunctions are of advantage. They may be used with service during
convalescence from the severe acute diseases which have not only
reduced the patient's weight, but have so affected the digestive and
assimilative functions that a return to health is materially retarded.
A brine bath (page 31) should precede the inunctions, both of
the; delicatk child
143
characteristics in common that they constitute a class themselves,
and as such warrant our attention.
Normal Development. — The average child, at the various periods
of early life, conforms with a certain degree of regularity to the mental
and physical development which by long association we have come to
regard as normal. Thus a standard may be said to have been estab-
lished, and it is up to this standard that we expect the growing child
to measure. This is what we look upon as the average of physical
and mental development. A few children exceed these requirements ;
they are stronger and larger at the sixth month than the average
child at the ninth month. Again, older children at the fourth or fifth
year are in every way equal to their normal playmates a year or
two older.
Abnormal Development. — On the other hand, there are children
who are born with a reduced vitality, or who, through faulty manage-
ment, usually in relation to feeding, acquire a reduced vitality.
vSemi-invalid adults almost invariably beget semi-invalid children.
If the parents are of average health and of good habits, and the de-
bilitated condition of the child is due to faulty management and
nutritional errors, the result of proper dietetic and hygienic manage-
ment is usually prompt and satisfactory. With the persistently deli-
cate, the offspring of physically enfeebled parents, the results are
less satisfactory.
Treatment. — By proper regulation of the habits of a delicate
child, however, as regards all the details of his daily life, a far better
adult is produced than if no such effort had been made. In other
words, a diet and general regime of life best adapted to the individual
in question will invariably improve the physical condition of that in-
dividual. This applies to the strong as well as to the delicate, ta
the growth and development of the young of the lower animals as
well as to the offspring of man. It is the poorly developed, delicate
child that we are particularly to consider — the undersized, frail,
small-boned, under-weight child, whose appetite is persistentlv poor
or capricious, who sleeps poorly, tires easily, is usually constipated,
who is subject to catarrhal conditions of the respiratory tract, and
whose powers of resistance generally are diminished.
On assuming the management of one of these children it is
absolutely necessary to make a thorough examination, followed
in some instances by a few weeks' observation, in order to become
acquainted with the case in its individual aspects, to learn idiosyn-
crasies, and to eliminate the factor of actual disease as a causative
agent. When we demonstrate to our satisfaction that the child
is free from such diseases as tuberculosis, syphilis, and malaria;
when we have eliminated by properly directed treatment all causes,
such as adenoids, phimosis, adherent clitoris, vaginitis, or parasitic
and irritant skin lesions, which may have had a deterrent influence
144
NUTRITION AND GROWTH
Upon growth ; and when we have satisfied ourselves as to the actual
condition of our patient, we are in a position to lay down definite
rules of management.
Every child has a distinct function to perform. As soon as he
is born he is confronted with a serious problem — the problem of
growth, physical and mental. Inasmuch as this growth and develop-
ment depend, above all things, upon a properly adapted food-supply,
it must be our first step to provide such nutriment as will be most con-
ducive to it. As growth takes place in all parts of the body through
cellular activity, the nutritive elements which support cell prolifera-
tion must be important constituents of the diet, and among these
the proteids are of prime importance ; hence in the management of
these children a point to be remembered in the adaptation of the food
is the necessity of feeding as rich a proteid as the child can assimi-
late. The younger the child, the greater the necessity for growth.
Regular Weighings Necessary. — An infant should be weighed at
regular intervals, and if under one year of age, should not be con-
sidered as doing even passably well if not gaining at least four ounces
weekly. When a baby remains stationary in weight its development
is invariably abnormal. When stationary or when only a slight gain
of one or two ounces weekly is made, we will always find after
a few weeks that there is malnutrition, in spite of the apparent
gain, as will be evidenced by the symptoms of beginning rickets —
anemia, the characteristic bone changes, flabby muscles, and a
tendency to disease of the mucous membranes. Delicate infants
should be weighed daily at first; then, as improvement takes place,
at inter\^als of two or more days, but never less frequently than once
a week, if under one vear of age, no matter how vigorous they may
become. The weighing keeps us directly in touch with the child's
condition, but since the increase may be in fat alone, an occasional
examination of the child stripped is necessary to tell us whether
there is substantial growth in bone and muscle.
Feeding Infants. — When it is demonstrated that a child will not
thrive on the breast of the mother, another breast should be substi-
tuted, or an adapted high-proteid cow's milk should form the diet in
part or in whole. If the child is bottle-fed and it is demonstrated
that proper growth and development are impossible on cow's milk,
on account of proteid incapacity, then a wet-nurse should be secured.
When, after the first year, more liberal feeding is allowed, the
necessity for a high proteid in the food selected is as urgent as before.
This applies to those children who are brought to us showing evi-
dences of late malnutrition, as well as to those whom we have had
under our care from early infancy.
An important element in the diet up to the third year is milk.
A child from the first to the third year ought to receive one quart of
milk daily. Unfortunately, many debilitated children have a very
THE DELICATE CHILD I45
poor capacity for fat assimilation. When given full milk in as
small an amount as one pint daily, they often develop foul breath,
coated tongue, and loss of appetite, or they suffer from frequent
attacks of acute indigestion. The milk is necessary, not because
of the fat, which can easily be dispensed with, but because of the
high percentage of proteid which it contains — from 3 to 4 percent.
When this fat incapacity exists, the milk is said to "disagree," but
skimmed milk will be taken without inconvenience. Enough sugar
may be added to bring the percentage up to seven, in order that it
may replace the fat, for fuel. Skimmed milk with sugar added
furnishes a food of no mean order. Too much milk, however,
must not be given. When large quantities, more than one quart
daily, are taken, the desire for more substantial nourishment, such
as eggs, meat, and cereals, is removed.
At the completion of the first year, keeping in mind a high
proteid (page 82), begin with scraped beef, at first one teaspoonful
once a day. in addition to the cereal and milk. If this is well borne,
and it usually is, a teaspoonful may be given twice a day, and later
three times a day. It may be given immediately before the bottle-
feeding. Eggs should be brought into use from the twelfth to the
fifteenth month. At first one-half an egg, boiled two minutes, is given
mixed with bread-crumbs. If well borne, a whole egg may be
allowed. The cereals used should be those most rich in vegetable
protein, such as oatmeal, containing 16 percent of proteid, dried
peas, 20 percent of proteid, and dried beans, containing 24 percent
of proteid. The peas, beans, and lentils should be given in the
form of a puree.
Diet after the First Year. — If the child after the second year has
an indifferent appetite, reduce the quantity of milk; never allow
more than one pint of skimmed milk daily for the first week or
two. Many delicate children who apply for treatment after the first
year of age have been subjected to as grave errors in diet as are seen
among the bottle-fed. Starch and milk oftentimes furnish the only
means of nutrition up to the fourth or fifth year, the starch used
being generally in the form of bread, crackers, and ill-cooked cereals.
In one case four quarts of milk were taken daily by a boy of seven
years.
It will be seen that it is our aim in this class of children — the
delicate, undersized, slow-growing class — to give as liberal a nitro-
genous nourishment as is compatible with the digestive capacity
of the patient. But if the child has had rheumatism, or if there is
a tendency to lithiasis, the use of a large amount of meat is con-
traindicated. It is in such children that the high-proteid cereals
are particularly valuable. In a general way, from early life the
diet of the delicate child should consist of milk, suitably adapted,
with highly nitrogenous cereals added, when permissible. Many
146 NUTRITION AND GROWTH
delicate children of the "runabout" age who cannot digest milk
containing 4 percent of fat will easily digest butter fat when spread
on bread or potatoes. In this way I often use it to supply fuel to
act as a proteid-sparer. Oatmeal-water, or oatmeal jelly, mixed
with the milk should be ordered at the seventh month. When age
allows, the addition of raw or rare meat, poultry, eggs, and purees of
dried peas, beans, and lentils should be given. Boxed, "ready to
serve" cereals are never given ; raw cereals are used, which are cooked
three hours. While a high-proteid diet is desirable, other things
are necessary. Green vegetables, animal fats, the ordinary cereals,
cooked and raw fruits, are required to furnish the necessary acids
and salts, as well as the necessary variety. In short, the ideal diet
for a delicate child is that combination of foods which, while imposing
the least burden upon the digestive organs, supplies the body with
material exactly sufficient for its needs, and such a food must be
rich in nitrogen. (See dietary, page 128.)
Baths. — On account of the fear that a delicate child may take cold,
the bath is often omitted. Every child, both the well and the deli-
cate, after the second week should be tubbed daily. The delicate
particularly require it. The salt bath (page 31) is usually advised.
The best time for giving the bath is at bedtime, and in order to
avoid all chance of exposure the temperature of the room should be
elevated to 80° F. The temperature of the water may vary. It
should never be above 95° F. except for very delicate young children
in whom there is a tendency to a subnormal temperature. Even
in these cases the temperature of the bath should never be higher
than the temperature of the body. In the frail and in the very
young the bath should not be continued over five minutes. In
older children, those of eighteen months or over, if the physical
conditions allow, a distinct advantage will be gained by a reduction
of the temperature of the bath while the child is in the water. An
immersion in water at 90° F., followed by a gradual reduction during
the space of five or six minutes to 70° F., should, upon brisk rubbing,
be followed by a quick reaction. For children after the third year,
a graduated cold spinal douche has served me well. (See Spinal
Douche, page 29.) If the reaction is not good, if the extremities
are cold and are slow in becoming warm, the reduction in the tem-
perature should be less or none at all. In the very poorly nourished,
a reduction below 80° F. should not be attempted. Following the
drying process, primarily for the benefit of the massage, goose oil or
olive oil should be rubbed into the skin over the entire body for from
five to ten minutes. The bath and the massage inunction, besides
favorably influencing nutrition, are a very effective means of inducing
sleep.
Fresh Air. — Delicate children are usually deprived of a proper
amount of fresh air, for the same reason that they are insufiiciently
THE DEUCATE CHILD 147
bathed — the fear of making them ill. All children need an abundance
of fresh air, both in illness and in health. The robust and the delicate
require it, and to the delicate it is much more essential than to the
robust. As many hours daily as practicable should be spent out of
doors. The time thus spent depends upon the season of the year
and the residence of the child, whether in the city or the country.
In the city, during the colder months with pleasant weather, the
child should spend at least five hours daily in the open air, dividing
the day into two outing periods — from 9 to 1 1.30 in the morning and
from 2 to 4.30 in the afternoon. On very cold days, 20° F. or below,
on stormy days, and on days with very high winds, the child is
given his airing indoors. He is dressed as for out of doors, placed
in his carriage, and left in a room, the windows on one side of the
room being open. Not infrequently during February and March
delicate children will be prevented from going out of doors for
several consecutive days. If some means for a daily systematic
indoor airing is not provided, these children will often go backward,
no matter how excellent the other management. The first symptoms
are loss of appetite and the ability to assimilate the food. In my
private work among athreptics, the child is placed in the baby-
carriage or in a basket and allowed to rest before an open window
for ten or twelve hours of every twenty-four, with a hot-water
bottle at his feet. Here he is fed, being removed only temporarily
to warmer quarters for a change of napkins. I have three roof-
gardens in operation. A boy patient nine months of age has been
in the street only once in four months, then only in going to church
to be baptized.
Sleep. — The delicate child requires no more sleep than does the
strong, and the rules governing this matter at the various periods
of life are the same both for the strong and for the weak, (See
Sleep, page 27.) The sleeping- room of the delicate child should
always communicate with the open air by a window, either directly
or through an adjoining room. A satisfactory method of ventila-
tion is by the window-board (page 43). The child should occupy
the room alone, if possible, sharing it neither with an adult nor
another child. This applies to all ages, but is particularly necessary
after the second year.
The Nursery. — The temperature of the nursery, day or night,
should never be above 70° F., during the colder months, and in the
very young, or in those who are difficult to keep covered, it should
not go below 65° F. at night.
Delicate children of the "runabout" age are very susceptible
to colds. In the management of such children it is necessary to use
every precaution against exposure. The most frequent way of
exposing a child to cold is bv allowing him to sit on the floor. To
keep the child of from ten months to three years of age off the floor
148 NUTRITION AND GROWTH
during the winter months, and thereby to eUminate this means of
exposure, is a very difficult matter. In fact, with active children
learning to walk, or who have just learned to walk, it is practically
impossible under the usual conditions. During the colder months
there is always a current of cold air near the floor, and allowing the
child to creep in winter, even if the floor is protected by rugs and
carpets, is one of the surest ways of permitting him to take cold.
If he is allowed to walk on the floor he is soon very sure to sit down.
If he is not allowed to creep and walk about at will, he will not get
the proper exercise and will show faulty development. For such
cases, I have found the exercise pen of immense service (see Fig. 4).
After being dressed, washed, and fed, the child is placed in the pen,
on a rug if desired. Toys are given him and the door is closed. He
can now roam about at will, stand up, sit down, creep or walk without
the slightest danger from drafts.
Influence of Climate. — Much has been written regarding the influ-
ence of climate in the type of case we are considering. According to
my observation, this matter does not deserve the attention it has re-
ceived. The city child in a well-to-do family is, as a rule, better off
for eight months of the year in his own home with its usual conveni-
ences. The benefits attributed to change in climate are usually the
result of a change not of climate but to more fresh air, which is af-
forded by the larger rooms of the hotel, with its loosely constructed
doors and windows ; and since the parent is desirous that the child
shall receive the full benefit of the change, he is kept in the open air
for a much longer time than when at home. The air at such a place
is more expensive, and consequently more appreciated than the air
at home. With sufficient heat and proper ventilation, we may make
our own climate. It is not to be denied, however, that a change of
residence for a few weeks from New York to Lakewood or Atlantic
City during March and April is sometimes of advantage.
From the first of June to the first of October the delicate child
should not remain in New York city. The humidity and the heat
which may prevail for protracted periods during this time render it
unsafe, particularly during July and August. The seashore for the
entire summer is not to be advised. The children whom I have sent
inland to the country and to the mountain have, as a rule, returned
in the autumn in a much better physical condition than those who
spent the summer by the sea.
Clothing. — Thin, poorly nourished children require more clothing
than do those physically normal. A fairly good index as to whether
a child is sufficiently clad is the condition of his lower extremities.
The forearm and hand cannot be relied upon. The legs and feet of
every child should always be warm to the touch.
As to the nature of the clothing: A mixture of silk and wool
next to the skin is most desirable. As a second choice a mixture of
THE DELICATE CHILD 1 49
wool and cotton is used. The linen mesh, often useful in the vigo-
rous " runabout," is not to be advised in the delicate.
Exercise. — Moderate exercise is to be encouraged. But it should
never be allowed to the point of fatigue. In large cities all delicate
" runabouts" from three to five years of age should be allowed to walk
not more than six blocks in going to the playgrounds. If the distance
is greater, the child should ride part of the way, play or walk for a
time, and then be placed in the carriage or cart and ride home.
Younger children, two or three years of age, should be wheeled both
ways and taken out at the park for a run when the weather con-
ditions permit.
Midday Nap. — Every day after the midday meal the child, regard-
less of age, whether two years or six, should be undressed and put
to bed for two hours. He should be left alone in the room, and
whether he sleeps or not he should remain in bed for the two hours.
Entertainment. — Entertaining play is necessary, but every kind of
excitement, such as children's parties, emotional plays at the theater,
and rough play with older children, should be avoided.
Education. — The delicate child under eight years of age should be
taught only to the extent of strict obedience and good habits. Other
than this he should be a little animal. There should be no teaching
in the ordinary sense of the term, no mental stimulation, until the
child is physically able to bear it. When school-work begins, which
in this class of children should never be before the eighth year, the
studies should be made easy and the school-hours short. Such chil-
dren should never be crowded. I usually direct that they attend
only the morning session.
The delicate child should be carefully watched from the time it
comes into our hands until it reaches the normal or until the period
of development is completed. While the scheme of management
as outlined will not always be attended with brilliant results, it
will not be in vain. Many lives will be saved, and as a result of
the increased acquired resistance, stronger men and women will be
added to the race than would otherwise have been possible.
Now and then I meet with a case among the well-to-do in which,
because of prolonged faulty feeding or vicious heredity, the vital
spark is so low that, fan it as we may, no impression is made upon it.
As a rule, these stubborn cases are the offspring of alcoholism and
debauchery. They are thin, anemic infants; thev develop into thin,
anemic children, and into thin, anemic adults. The delicate and
degenerate are found in all the walks of life, but they are especially
numerous in dispensaries and in children's institutions.
Much of the work of the pediatrist is with the weakly of the so-
called " better class." His success in the management of these
delicate children depends largely upon the home cooperation, and a
promise of this he should obtain before taking the case. The
I50 NUTRITION AND GROWTH
parents must be taught that the development of the intellect, the
character, and the body go hand in hand, and that a vigorous intel-
lect is rarely found without a vigorous body. It is impressed upon
them that the body is more than a machine. It has delicate organs
to hold, to keep in repair and supply with energy. It has a nervous
organization; it has sensibilities. The normal exercise of all these
functions demands the normal nourishment of the body. In my
experience, family cooperation in a few instances has been difficult to
obtain. The parents began well, but soon tired of the extra work
required. The care of the young has always been undertaken in such
a wretched, unscientific manner that it is difficult to make the un-
trained mind appreciate the necessity of careful attention to details
in his management.
The Child vs. the Animal. — It is a startling fact that 75 percent of
all children do not get as scientific care and attention, as regards the
selection of food, housing, and exercise, as do the calves and colts, the
lambs and pigs, of any high-class stock-farm. Is this because the child
has no market value in dollars and cents? In France, during the past
few years, this defect in the people as a whole has received govern-
mental attention; and on account of the diminished birth-rate, the
value of a human life is beginning to be appreciated. That the subject
of better care of the young deserves our earnest consideration is well
illustrated by the statement recently made in the House of Commons,
by Sir William Anson, Parliamentary Secretary of the Board of Edu-
cators, that sixty thousand children of those attending the London
schools were physically unfit for instruction. The Adjutant-General
of the English Army Medical Service reported that one man in every
three offered as recruits ought to be rejected.
The two bills now before Congress at Washington, relating to
the formation of a bureau to investigate the condition of children,
shows that our own country is beginning to realize a long-felt need.
MARASMUS ; ATHREPSIA ; INFANTILE ATROPHY
Under this title will be considered those cases of marasmus
which are associated with and dependent upon derangement of
function of the gastro-enteric tract. Tuberculosis, syphilis, and
atelectasis are consequently excluded, these affections being con-
sidered elsewhere under their respective headings.
Marasmus is seen most frequently in young infants under nine
months of age. Cases are frequently seen, however, from the ninth
to the twelfth month, and comparatively few between the twelfth and
eighteenth months. A great deal of research work has been done
in marasmic infants in order to determine the nature of the condition,
but as yet no satisfactory explanation has been offered. The disease
is unquestionably due to defective intestinal assimilation. The
principal fact that disproves the existence of any atrophic condition
marasmus; athrepsia; infantile atrophy 151
or any necessarily severe derangement of function is that these cases
very often make complete recoveries, becoming perfectly normal
children after six months of treatment.
The story of these cases, which we have heard hundreds of times,
both in out-patient and in private work, is about as follows: The
mother could not or did not nurse the baby. The child was put on
cow's milk, which was usually given too strong or in too large
quantities— oftentimes both errors were combined, or the milk may
have been too old when used and improperly cared for; in any
case the milk disagreed, the child was made ill, there was loss in
weight, cow's milk was discontinued, and one of the infant foods,
alone or combined with milk, was given; but, the child's digestion
being thoroughly disordered, the foods failed to agree. There was
vomiting or regurgitation with undigested green stools, or both
combined, while the loss in weight continued. The child may have
been inherentlv weak or there may have been a cow's-milk idiosyn-
crasy to help account for the lack of success in the milk-feeding.
Usually there followed a series of experiments with different kinds
of food and methods of feeding, the vomiting, diarrhea, or colic
continued with wasting, and when the child reached the dispensary
or office he was perhaps six months of age and weighed from six to
nine pounds, presenting a typical athreptic picture. Some of these
children are born with a digestion that is apparently incompatible
with cow's-milk mixtures. Others have their digestive capacity for
cow's milk hopelessly deranged by improper feeding methods. The
majority of the cases occur among the overcrowded tenement
poor— the w^orst possible environment for a delicate infant. There
is little or no proteid assimilation, so that any approximation to
normal growth is impossible. They may also possess a poor fat
capacity, and if there is also a diminished sugar capacity the proteids
of the tissues are drawn upon to supply heat and energy, with
resulting progressive emaciation. Heredity, environment, and the
season of the vear, all influence the prognosis.
Treatment.— An important determining factor, however, as to the
child's future, depends upon whether or not he can have the advantage
of a wet-nurse. That a great majority of the cases of simple athrepsia
recover, and often recover promptly, making a most satisfactory
growth, when a wet-nurse is secured, is proof, as above stated, that
the condition depends more upon the nature of the nutrition than
upon the patient, so far as relates to any peculiar systemic state or
pathologic condition. In securing a wet-nurse the physician's duties
are by no means completed. The patient may not take kindly to
the breast and he will have to be taught breast-nursing. A great
deal of time may be required in teaching older infants, those who
have been on the bottle for seven or eight months. To this end,
various devices may have to be used. For the first nursing it is
152 NUTRITION AND GROWTH
well to allow the child to go for an hour or two beyond the feeding-
time in order that his appetite may be voracious. It is advisable
also to give the first few nursings in a darkened room with the
person who has been accustomed to feeding the patient very near.
Sufhcient milk should be forced from the breast to enable the child
to taste it. A little powdered sugar sprinkled on the nipple is a good
means of increasing his interest. In some instances it has been
necessary to cover the wet-nurse with a blanket or sheet, leaving
only the breasts exposed ; or it may be necessary to use the nipple-
shield (Fig. 7) for a few days in order gradually to accustom the
child to the change. I have yet to see a case in which success did
not follow persistent effort. Oftentimes the nurse's milk will not
agree at first; but this is not surprising and need cause no dis-
couragement. Breast-milk ordinarily is a much stronger food
than the child has been accustomed to, and it may produce vomit-
ing or colic or diarrhea. When indigestion follows, the nurse's
milk should be modified by giving the baby weak barley-water or
plain boiled water before the nursing, in case he nurses well, or after
the nursing in case he nurses poorly. One or two ounces of breast-
milk at a feeding is all that these patients can be expected to take
during the first few days. The amount obtained may readily be
determined by weighing the patient, without the trouble of undressing
him, before the nursing, and then weighing him at intervals of from
three to five minutes after the nursing has commenced. An ounce
of breast-milk is practically an ounce avoirdupois. These children,
if they are not too weak, will take greedily almost anything from the
bottle. The addition of an ounce or two of barley-water or plain
water dilutes the milk and renders it easier of digestion, and furnishes
at the same time the necessary fluid for the child. The most unprom-
ising cases of marasmus are not to be despaired of, or the treatment re-
laxed, although the physician should be cautious in his prognosis.
Hospitals and institutions for children always carry a certain number
of these cases. It is not infrequent to find miliary tuberculosis at
autopsy where it was not suspected during life, no clinical signs of
fever having been present. If the child is too weak or indifferent to
swallow, the wet-nurse's milk may be expressed, diluted, and given by
gavage. I have in a few instances peptonized the wet-nurse's milk.
Illustrative Case. — The most pronounced and the most hope-
less recovery case coming under my observ^ation was seen by me
in consultation in one of the suburbs of New York. The child
was four months old and weighed five poimds. He was ema-
ciated to a skeleton, having weighed eight pounds at birth. The
temperature for several days ranged between 92° and 94° F. A
trained nurse and an unusually intelligent mother were in charge.
I doubted the accuracy of the thermometer reading, and different
thermometers were used. The temperatures were taken by the rec-
marasmus; athrepsia; infantile atrophy 153
turn. I took the temperature myself on one or two occasions with
my own thermometer and found the reading correct. The attending
physician had also taken it repeatedly, so that there was no doubt
as to the matter. The child was too weak to nurse. The breasts
were accordingly pumped, and for each feeding he was given one-half
ounce of breast-milk with an ounce of barley-water, to which a few
drops of sherry wine were added. This was given by gavage at
two-hour intervals. He was wrapped in flannel and w^ool and sur-
rounded with hot-water bottles. The food was retained and digested.
In four days he could nurse, and was allowed to take a small amount
from the breast and finish the meal with barley-water. The tem-
perature gradually rose to the normal. More breast-milk was
allowed as he proved able to care for it, and the child made a perfect
recovery, weighing eighteen pounds when he was nine months old.
This case demonstrated to me that a marasmic child is never a
hopeless case until he ceases to live. Unfortunately very few
marantic children can have the benefit of a wet-nurse, but without
her the majority of these cases are hopeless. I have seen such cases
take their modified milk or w^hatever was given them without
inconvenience. The stools may be offensive if cow's milk is given, or
there may be constipation or the stools may appear perfectly normal.
As a rule, there is no serious diarrhea or any other evidence of an
acute inflammatory process in the intestine. However, in spite of
fairly normal stools, the patient grows thinner and thinner. After
a time all food is refused, gavage is used as a last resort, and the
child finally dies. The autopsy shows nothing but pale organs with
perhaps a strip of hypostatic pneumonia. Now and then one of
these cases in a children's institution or in a hospital recovers without
a wet-nurse, but it is the exception proving the rule. Put these
athreptics on a wet-nurse, as I do at every opportunity, and many
of them thrive in spite of the well-known unfavorable influence
exerted by institutional life upon the very young. In addition to
putting the athreptic baby on the wet-nurse, his stomach should be
washed once daily and he should live out of doors.
Outdoor Life. — Next to the wet-nurse, I know of no measure
fraught with so much good as is outdoor life. The season of the year
exerts considerable influence on the prognosis. The athreptic bears
the heat and humidity very badly, and the early summer mortality of
all large cities is materially increased by these children, who wilt and
die in institutions and tenements with the first two or three days of
continuous hot weather. Parents of such children residing in a large
city who can afford it, should send them to the country not later than
June ist, to return, in this latitude (New York city), not earlier than
October ist. During the day the child should be on a porch or in the
shade continuously. At night the windows of his sleeping-room
should be wide open. During the colder months if the child is too ill
154 NUTRITION AND GROWTH
to be taken out of doors he should have from morning until evening
a continuous indoor airing (page 36), and the sleeping-room should
always communicate with the open air. The roof-garden in large
cities is a most valuable aid in the management of athreptic children.
Tenement Cases. — While much has already been said about this
most interesting and important subject, one phase of it has not been
touched upon. I refer to the athreptic infant of the tenement, and
those others in private life for whom a wet-nurse is impossible. They
furnish by far the largest number of our marasmic patients. Perhaps
the most frequent error in the management of these cases is an en-
deavor to select at the start a food for the child to thrive upon. In
doing this, almost invariably a stronger food is selected than the child
is capable of digesting, and he is made worse by the attempt. Our
ultimate object in these infants will be more readily attained if, at
first, we attempt only to supply the child with a food upon which he
can exist without loss in weight. The number of calories necessary
for an athreptic child is not great. It must be remembered, further-
more, that we are not dealing with a case of infant-feeding as the
term is commonly understood. True, we are feeding an infant, but a
sick infant, and the methods of feeding used in the comparatively well
do not apply here in all respects. The problem of nourishing these
children is to be considered from two standpoints — that of the food and
that of the baby, with special reference to his organs of digestion.
The stomach, in many of these infants, is dilated, with a consequent
lack of motility. Residual undigested food remains long after feed-
ing. There has been a constant fermentative change, with the pro-
duction of lactic and butyric acids, resulting in local changes of an
inflammatory nature in the mucous membrane of the stomach, so
that not only must the organ be prepared for the food, but the food
must be adapted to the stomach capacity, and when this is done, when
both receive due consideration, we are much more likely to succeed.
Stomach-washing . — In all of these cases, for the first few days
of treatment, I wash out the stomach with sterile water, regard-
less of the presence of vomiting and regurgitation and regardless
as to whether the child is bottle-fed or breast-fed. It is often sur-
prising to note the amount of thick mucus and undigested food that
will be w^ashed from a stomach from which there has never been
vomiting. The daily washings enable the child to take more food
and stronger food. It may be necessary to continue the washings
for days. They may first be discontinued when the water siphons
clear and without mucus. They should be repeated if there are
indications calling for it, such as regurgitation of sour water or
mucus or a loss of appetite. In a case seen recently in which there
was chronic gastritis with athrepsia, washings were continued at
gradually lengthened inters^als for six months.
Feeding. — If the case is one with pronounced stomach involve-
marasmus; athrkpsia; infantile atrophy 155
ment, a 3 percent milk-sugar solution is given for twenty-four hours
in quantity suitable for the age and size of the patient. The follow-
ing day barley-water No. I is given, to which sugar is added to make
the mixture 5 percent.
Cow's Milk. — While it is doubtful if the child can take cow's
milk after this period of stomach-rest and stomach-washing, it may
be attempted. Two drams of as safe milk as can be obtained
is added to every second feeding of the barley-and-sugar water.
If it agrees, after a day or two, two drams are added to each feeding,
with a gradual increase of a dram every two or three days. The
intervals of feeding, for children under one year of age, may range
at from two to three hours. It is rarely advisable to feed even the
most delicate athreptic oftener than once in two hours. If the milk
can be retained and assimilated in the strength of one-fourth milk and
three-fourths barley with 5 percent sugar, or if an equal quantity
of milk and sugar-water alone is found to agree, the child will begin to
grow and general improvement will follow rapidly. If the cow's milk
is not well borne, skimmed milk (page 85), or a weak cream mixture
— one-half dram of cream to a feeding — may be tried. It is practically
impossible to have whey made properly outside of a hospital labora-
tory or an intelligent home. In using whey it may be given in quan-
tities suitable to the age of the patient. The prescribing of cream
among the poor is a hazardous procedure for these infants. It may
be old, improperly cared for, and swarming with bacteria. If there
is a tendency to looseness of the bowels the diarrhea is thus made
worse. Cream mixtures rarely succeed as foods for athreptic chil-
dren. I use it only among those who can properly care for it.
Condensed Milk. — I have found that in the out-patient athreptic
the much-abused condensed milk fulfils a useful function. It is
the cleanest food we can give the dispensary baby. It is the cheapest,
the most easily kept, and the most easily digested milk that can be
furnished him. Consequently when cow's-milk feeding is imprac-
ticable or when it disagrees, I give condensed milk, beginning with
one-half dram, which is added to the barley-water or to the plain
water for every second feeding, later to every feeding, increasing the
quantity gradually as the child shows an ability to digest it. The
patient must be seen frequently and the stools carefully examined
in order that an increase in the food strength may be made as soon as
conditions allow. The mother is told to bring the napkins to the
dispensary, the child is weighed at each visit, every second day,
and it is most gratifying to see how well some of them gain in weight,
not because they are getting an ideal food by any means, but because
it fits the case, temporarily. Condensed milk is thus used as a
stepping-stone to something better. When the child has taken it with
benefit for a month or six weeks, cow's milk is attempted if the time
of the year is between October and the following June. After June ist
156 NUTRITION AND GROWTH
I would continue with condensed milk, as a baby showing some degree
of anemia and rachitis as the cooler months approach is to be pre-
ferred to the risk of attempting cow's-milk feeding, with poor milk,
in the hands of overworked or ignorant mothers.
In beginning cow's milk, in order to avoid sudden radical changes I
replace one feeding of the condensed-milk mixture daily with one feed-
ing of a weak cow's-milk mixture. In some cases this will produce
illness and must be stopped ; in others, it will be well borne. When
it is found to agree, two feedings should replace two condensed-
milk feedings daily. In this way, by increasing by one the number
of cow's-milk feedings every third or fourth day, entire cow's-milk
feeding may safely be inaugurated. The strength of the cow's milk
should not, of course, correspond to that suggested for well babies.
For a child of six months a three-months' formula may be given.
As the child improves, the strength of the milk may correspondingly
be increased. In this way 1 have treated successfully a great many
tenement athreptics.
Some children will be able to take and properly care for only
two cow's-milk feedings daily; others will take every second feed-
ing of cow's milk. I have a patient at the present time aged four-
teen months. He will take two cow's-milk feedings daily with com-
fort, but when the third is given he is invariably made ill. Some
will not be able to take a particle of cow's milk. When this is the
case, the condensed milk should be combined with a gruel, such as
oatmeal, which contains a high percentage of proteid. These cases
may also be given beef- juice at a very early age. I often use pure
cod-liver oil, from fifteen to thirty drops, which is usually taken three
times daily without disturbance. The tenement athreptic is given
the benefit of as much fresh air as possible. He is also given the
advantage of the daily tub-bath and the oil rub.
MALNUTRITION IN INFANTS
I am often asked by students the difference between malnutrition
and marasmus in infants. While hard and fast lines cannot be drawn
as to where malnutrition ends and marasmus begins, there is a vast
difference between the two conditions. Malnutrition may best be
described as the first stage of marasmus. Every child with marasmus
must first have undergone a longer or shorter period of malnutrition.
In malnutrition the infant is under- weight, his gain being slow and
irregular, the muscles are soft, and if the condition persists, bone
changes, indicating rachitis, appear. Malnutrition may be the
result of faulty digestion and assimilation engrafted upon faulty
feeding, often combined with overfeeding. The patient shows
evidence of indigestion in a distended abdomen and in stools that
are far from the normal, or there may be no intestinal derangement
whatever, the malnutrition being due to the fact that the child's
diet for months had consisted of food that did not contain the
MALNUTRITION OF INFANTS
157
nutritional elements required. Infants who subsist on a diet of
condensed milk or the malted infant foods, without cow's milk,
almost invariably show signs of general malnutrition.
A case due to high-fat feeding was recently seen by me. The
patient was a male, six months of age, weighing thirteen pounds,
resident of a New York suburb where the conditions are most
healthful. His fontanel was slightly depressed, the muscles were
soft and flabby, the ribs beaded, and the child had lost his appetite
and suffered from constipation. A history of the feeding showed
that he had been getting a cow's-milk mixture containing approx-
imately 6 percent fat, 4 percent sugar, and 2 percent proteid. In
this patient the indigestion, loss of appetite, and constipation
were unquestionably due to the high percentage of fat. The energy
exerted in digesting the food almost counterbalanced the benefit
derived from it, the result being a very slow gain in weight.
Treatment. — Diet. — The management of malnutrition due to such
causes consists in correcting the digestive errors, in using castot oil or
calomel with stomach-washing, and in adjusting the food to the child's
requirements and digestive capacity, alw^ays remembering that a child
who should have from 3 to 4 percent of fat cannot be expected to
thrive on i percent, as is the case when condensed milk is given; nor
can he be expected to thrive when the use of a 6 percent cow's-milk
mixture is long continued. Likewise very low proteid or very high
proteid will be followed by malnutrition, the one producing indiges-
tion and interference with the assimilative powers, the other supply-
ing too little nutrition to the organism. In either event, the child
does not get the nutrition required. The amount of proteid given in
condensed milk is rarely above 0.5 percent. The proprietary meal
foods and condensed milk mentioned elsewhere are useful in certain
types of illness and in convalescence from illness. They must not,
however, be selected as the sole articles of diet. A mistake fre-
quently made in the feeding of these cases is to give the food at too
frequent intervals. At the sixth month three-hour feedings, six
in twenty-four hours, are best, even though the food is weak. The
stomach will bear stronger food sooner when given at longer intervals
than it will when given at intervals of two and one-half hours.
When the child is nine or ten months of age, four-hour intervals
usually answer best. In some it may be necessary to continue with
the three-hour feedings. Cow's milk should be the basis of the
diet, given according to the suggestion in the section on IMarasmus.
In many cases cereal gruels made from barley or oatmeal may be
added with advantage. Malt soup (page 98) may often be used
with success in these patients. A milk formula below that indicated
by the child's age may have to be given for a long time. Thus, w^hen
six months of age he may be able to take but a three-months' formula ;
when nine months of age, a six-months' formula. I have constantly
under my care infants who cannot take cow's-milk mixtures cor-
158 NUTRITION AND GROWTH
responding in strength to that usually taken by well infants of the
same age.
Hygiene. — Attention to the matter of outdoor life, indoor airing on
inclement days, and residence in the country during the heated term
is of great importance in the general management. During the
cooler months the child should receive inunctions of unsalted lard
or goose oil after the daily evening bath. Constipation, if present,
is treated by the oil method (see page 173).
TARDY MALNUTRITION
Malnutrition with tuberculosis and syphilis is not a part of our
subject. In the sections on Malnutrition in Infants and Children
it may be thought by some that there is repetition of what is said
under the title of The Delicate Child. While the management neces-
sarily is along the same hues, two distinct types of children are
represented. The marasmic and malnutrition infant or young child
may be but temporarily delicate. When the simple malnutrition
case recovers it may develop into as normal a specimen of robust
childhood as could be desired. The delicate child as I have endeav-
ored to describe him is inherently delicate, and our efforts are toward
improving his condition, with the hope perhaps, but with no great
assurance, that he will some time become a robust adult. Tardy
malnutrition is seen in children of the school-age. They are deficient
in weight, in resistance to disease, and in capacity for work; they
are pale, thin, tired children.
Etiology. — Cases of tardy malnutrition as well as those of maras-
mus and infantile malnutrition are seen in all the walks of life,
among the wealthy, the so-called middle class, and among the poor.
Strange as it may seem, these cases, regardless of the station in life,
have one cause common to all — defective feeding. The scion of
wealth who is overfed, or badly fed — given food which is unsuitable,
and allowed the promiscuous use of sweets — may develop malnutri-
tion just as effectively as the child of the tenement who subsists on
fried meats, grocery milk, boxed breakfast foods, and other nonde-
script products of the bakery around the comer. There is a painful
lack of knowledge among all classes as regards the nourishment re-
quired by a growing child. He is fed to satisfy his appetite, and
when this is accomplished the parents believe that their duty is
done. How far they fall short of proper feeding is demonstrated
daily in out-patient clinics and in private work. Poverty is an oc-
casional cause of bad feeding in New York city.
Treatment. — I have repeatedly seen children from five to ten years
of age with marked malnutrition gain from three to five pounds the
first month under treatment which consisted simply in giving food
that they had a right to demand, properly prepared at definite inter-
vals. The school-child sufi"ering from malnutrition should be re-
moved from school temporarily and as much outdoor life as possible
TARDY MALNUTRITION
159
should be enjoyed by him, regardless of his station in life. Every-
thing of a strenuous nature should be avoided. He should be put to
bed early and encouraged to sleep late. A midday rest for one who
shows marked emaciation and diminished resistance is advised.
Illustrative Case. — The following is quite a normal history of an
advanced case of malnutrition in a girl seven years of age, and the
treatment is that which we usually employ. The mother brought the
girl to the out-patient service at the New York Polyclinic because the
child was pale, did not grow, and was always tired — too tired to go to
school, of which she was very fond, too tired to play with other chil-
dren, as had previously been her custom. There was loss of appetite,
no food being taken except on compulsion. Her weight was forty-one
pounds, her appearance as above described. There was no evidence
of congenital syphilis or tuberculosis. There was a secondary ane-
mia. The child slept in a badly ventilated room, she drank tea and
coffee. Cake, pastry, and sweets were her regular diet, and because
she did not eat at meal-times she w^as allowed to eat between meals
whenever and whatever she pleased. The following mode of life and
diet was prescribed. She was to sleep in the front room, known as a
sitting-room or parlor, with a window open at least six inches. She
was given three meals a day with nothing whatever between meals.
The diet consisted of red meat once a day, two or three soft-boiled
eggs daily, one quart of good milk daily if it agreed, and it did agree.
She was to have only natural cereals, such as oatmeal, cracked
wheat, and cornmeal — each of which was to be cooked three hours
the day before it was to be given. Baked or boiled potatoes and
one green vegetable were to form a part of the dinner at midday.
Stewed and raw fruits and plain puddings with home-made bread
and plenty of butter completed the dietary. She was put to bed at
7 o'clock and arose at 7 the following morning. An after-dinner rest
in a darkened room for an hour was insisted upon. Before retiring
she was given a brine bath (page 31), followed by a brisk drying with
a rough towel, after which her entire body was rubbed for ten min-
utes with olive oil. In one month a radical change had taken place.
She had gained four pounds in weight. Her color was good. She
complained no more of languor or fatigue. She was eager for sckool.
The improvement continued, and in ten weeks she made a perfect
recovery. In not every case will results be so prompt and satisfac-
tory, in some, a longer time will be required before pronounced
results are to be seen. Every child suffering from malnutrition of
this type cannot help being benefited more or less by such a regime.
Tonics. — The tincture of nux vomica, four drops in water before
meals, is sometimes given to these children in whom the appetite is de-
fective ; or one grain of the citrate of iron and quinin may be given
in one dram of equal parts of sherry wine and water. If constipa-
tion is present, the oil treatment (page 174) should be instituted.
GASTRO-ENTERIC DISEASES
ACUTE INTESTINAL INDIGESTION
This disorder is first referred to because, according to my obser-
vation, it is the most frequently seen of the intestinal disorders.
Its importance not being recognized, it receives but little considera-
tion in its bearing upon prophylaxis and treatment. The proper
appreciation and management of a disordered intestinal function
are essential to the solution of that most important problem — summer
diarrhea. As pointed out elsewhere, the intestine which furnishes
the most fertile field for bacterial growth is the intestine which is
persistently deranged.
The mortality of summer diarrhea in June in Greater New York
in children under two years of age is usually but from three hundred
to five hundred less than in August. The high June mortality has
been explained by the fact that it includes many cases of malnutri-
tion and marasmus ; but it must be remembered that it includes also
cases of a diminished intestinal resistance, which are ready subjects
for the almost invariable exposure to which every bottle-fed infant
is subjected at some time during the summer, when heat and humid-
ity aid in lowering the general vitality — exposure through infected
food. A close investigation of hundreds of cases of severe acute
disorders of infants has shown that a great majority of them are not
as acute as a superficial history would indicate. A complete history
in a case of acute gastro-enteric infection (cholera infantum) or
in an apparently severe intestinal infection with resulting colitis,
or in an acute colitis (dysentery), will show that the child had
defective intestinal digestion during the previous cold months,
and that the grave condition which he presented when brought for
treatment had been preceded for two or more days by simple diar-
rhea, probably without vomiting and with little fever, but he did
have green passages and he did have diarrhea. He therefore had
intestinal indigestion before the urgent symptoms of fever and pros-
tration developed. In about i percent of the cases of severe gastro-
enteric diseases of children in summer the onset is sudden, without
warning and with urgent symptoms.
Treatment. — The time to treat these cases of intestinal indiges-
tion, in order to be most effective in the prevention of severe toxemia
and grave lesions, is before the physician sees the patient. The reduc-
tion in the mortality rests in the education of the mother to the point
of realizing that a loose green stool is a danger-signal. When it
1 60
PERSISTENT INTESTINAL INDIGESTION l6l
occurs, she is to give a dose of castor oil, stop the bottle or stop the
breast, and give the baby boiled water or barley-water until the
physician can see the patient. Any physician who has children
under his care, whether in hospital, institution, out-patient, or pri-
vate practice, and who does not so instruct the nurse or mother,
fails in his obligation as a practitioner of medicine.
In the Breast-fed. — Intestinal disease of severity in infants fed en-
tirely on the breast is exceedingly rare. In a breast-fed baby it may
be necessary to discontinue nursing for from twelve to thirty-six hours.
The child is given one or two drams of castor oil and barley-water or
rice-water No. i (seepage 124), to which one-half or one-fourth
ounce of cane-sugar is added to the pint. While nursing is discon-
tinued the breasts should be pumped at the regular nursing hour so
as to keep up the flow of milk and relieve the pressure. Rarely wdll
other treatment be required.
In the Bottle-fed. — In the bottle-fed, greater caution will be neces-
sary. The management consists in continuing the carbohydrate diet,
which the well-trained mother has begun, until the stools approximate '
the normal, which may necessitate an abstinence from milk for three
or four days, bv which time it may usually be resumed. In resuming
the milk it should always be given in reduced quantities for the first day.
One-half ounce of skimmed milk may be added to every second feed-
ing or to every feeding of the gruel. If it is w^ell digested and causes no
return of the diarrhea, the amount of milk may be increased tenta-
tively every day or two by the addition of one-half ounce to each
feeding.
PERSISTENT INTESTINAL INDIGESTION
A greater part of this subject has been covered in the consideration
of the management of malnutrition and marasmus. It is again
referred to here in order to call attention to those cases which,
though mild in character, are so important an etiologic factor in the
acute intestinal diseases of summer. There is perhaps not enough
bow^el disturbance to interfere with the nutrition, but we have
learned that a considerable part of the summer mortality of acute
intestinal diseases occurs in children who have a reduced intestinal
resistance as a result of persistent intestinal indigestion.
A considerable number of infants do not have normal bowel
evacuations even for two days out of ten. There is constipation
which is neglected, or there is a passage of undigested or loose
stools. In some cases constipation alternates with diarrhea.
Occasionallv there is a sharp attack of diarrhea with fever. In
getting the history of our cases regardless of the nature of the illness,
we often learn that, as a rule, the infants have undigested stools.
There is always an unstable intestinal equilibrium. This condition
of intestinal indigestion is almost without exception due to errors
1 62 GASTRO-ENTERIC DISEASES
in diet — either unsuitable articles of food being given habitually, or
the food is too strong or the feeding intervals too short.
Treatment. — The management of each case is determined by the
age of the patient and the conditions of the family, and will be dis-
cussed in the sections relating to Nutrition, Substitute Feeding, and
Modification and Adaptation of Foods.
PERSISTENT INTESTINAL INDIGESTION IN OLDER CHILDREN
In such cases there may be a sufficient absorption of toxins of
an unknown nature from the intestinal canal to produce a wide range
of symptoms. Whether this causes pathologic conditions in other
organs it is not possible to state. It is assumed, however, that it
does. Comparatively little attention appears to have been given the
subject. There is no doubt whatever that it is a factor of great
importance in the nutritional and the so-called functional nervous
'disorders of childhood. One reason why little attention has been
called to the intestinal tract as an etiologic factor is perhaps because
the child is not necessarily constipated. Intestinal toxemia may exist
with one or two apparently normal passages daily and even without
the presence of indican in the urine.
In mv cases the conditions in which it has seemed to play a
part sufficient to form a symptom-complex have been in habitual
headache, in disorders of speech, choreic in character, in secon-
darv anemia, in habitual sleep-talking, in sleep-walking, and in gen-
eral irritability without apparent cause. Well children are natur-
ally bright and happy. When a child is persistently cross and
irritable, he is not a well child. Chronic papular eczema has
proved to be of intestinal origin in a considerable number of my
cases, particularly among the out-patient class. The condition
often regarded and treated as malaria is not infrequently due to
intestinal toxemia. Fever of a degree or two may be present for
protracted periods. Nearly every case which has come under my
care had been given at some time or other a course of quinin.
Such a patient is very apt to be habitually tired and languid. He
may be fairly bright early in the day, but in the afternoon he yawns
and complains of being tired and sleepy. The blood examination
fails to reveal signs of malarial infection, and quinin in full doses
furnishes no relief. The appetite may be satisfactory, the tongue
may show no signs of digestive disorder. The symptom-complex
which suggests to the mother the thought of worms is usually the
manifestation of intestinal toxemia.
Illustrative Cases. — An interesting case of this nature came under
my care a few years ago. The boy, aged three years, highly ner-
vous and irritable, was afflicted with day terrors — pavor diurnum.
The attention of the nurse was attracted to the condition by the
boy, who asked that the "bugs" be removed from his lap-robe
PERSISTENT INTESTINAL INDIGESTION IN OLDER CHILDREN 1 63
when he was in his go-cart. It was in the middle of winter and
there were no bugs present. I fortunately saw the boy on one of
these occasions and asked him to pick up a bug, which he tried to
do with his lingers. He could not understand why he could not
catch them. In this child the tongue was heavily coated and there
was moderate constipation, a laxative being required every third
day. There was an excess of indican in the urine. The boy was
taking a large amount of rich cow's milk daily. After stopping
this, a full dose of rhubarb and soda was given daily and the boy
was well in a week.
A boy five years old, under treatment at the time of writing, was
brought to me because of disturbance of speech. He was normal
until three and one-half years of age, when he had difficulty in the
formation of entire words. This had increased with the development
of other nervous phenomena. There was marked incoordination in
speech — dysarthria — due to choreic movements evidently of the
tongue and laryngeal muscles. The boy was exceptionally well
nourished and there was an absence of choreic movements in other
parts of the body. The knee reflexes were considerably increased.
He was easily excited. Hard play was followed by restless nights,
and he talked in his sleep every night, regardless of the habits of the
day. Inquiry into the diet failed to elicit any grave errors. He drank
one quart of milk daily, but milk had never agreed with him as an
infant. The bowels moved once daily. The movements were often
of foul odor and the mother stated that she was satisfied they were
too small. The case after three weeks showed striking improvement
on a non-milk diet with a daily laxative.
A third case seen was a girl six years of age who lived in the best
surroundings in a country district. She was pale, rather thin, and
below weight for her age. She was chronically tired and irritable
and had been so for two years. Examination of the blood showed
a secondary anemia, and of the urine a marked excess of indican.
She had been taking quantities of quinin. There was no constipation,
the child had an indifferent appetite. She favored milk and was
paid for drinking extra quantities of it — about two quarts daily being
taken. Marked improvement followed the treatment by an ab-
sence of milk from the diet and laxatives, after which she passed
from my observation.
The condition of intestinal toxemia is probably due to changes
taking place in the proteid content of the intestine. In the three
cases mentioned, milk was a considerable part of the diet; in fact,
in the majority of my cases, milk had been taken in considerable
quantities.
Treatment. — In my experience the management of these cases,
which has been most successful, has been the discontinuance of
cow's milk, with the further dietetic suggestions of but one egg
164 G ASTRO-ENTERIC DISEASES
every second day, with meat but once daily. Cereals, fruit, and
vegetables are taken as suggested in the dietary (page 128). In
place of cow's milk, malted milk is given, and to facilitate the
bowel action, a raw apple is given in the middle of the afternoon.
The patient takes an after-dinner rest for an hour or two. If the
constipation is obstinate, rhubarb and soda of the following strength
is used:
I^. Pulveris rhei S*"- ^X. .
Sodii bicarbonatis gr. viij
Syrupi rhei aromatic! 3ss
Aquae q. s. ad 3 j
M. ft.
Sig. — One teaspoonful once or twice daily
Or, what I prefer, if the child can take a capsule, is the following
for a child from five to eight years of age:
I^. Tinctur£e belladonnae gtt. ij
Tincturae nucis vomicae gtt. iv
Extracti cascarae sagradae gr. j-iij
Sodii bicarbonatis gr. iij
M. ft. capsula No. i.
Sig. — To be taken at bedtime.
The medication may be continued for three or four weeks, after
which time one dram of the syrup of the hypophosphites (Gardner's)
may be given three times a day. This may be alternated with :
J^. Ferri et ammonii citratis gr. xxiv
Elixiris simplicis gtt. xv
Aqua; q. s. ad 0 iv
Sig. — One teaspoonful three times daily after meals.
In the event of constipation following the use of the laxative,
the oil treatment (page 174) may be brought into use and continued
until the condition is relieved.
COLIC
But few children complete their first year without having severe
attacks of colic. In some cases the child thrives in spite of the
attacks, in others such a grave degree of indigestion exists that the
condition may prove most serious. The character of both human
and cow's milk, its ready decomposition in the intestine, with the
formation of gas, together with the lack of development of the
infant's digestive apparatus, explain in no small degree the frequency
of colic in the young. When cow's milk is used as in the bottle-fed,
we are dealing with a substance foreign to the infant's digestive
apparatus, and often colic is the outcome. Any condition that
will give rise to indigestion may, of course, be a cause of colic. Those
nursing or feeding on quantities that are too large or on milk too
COLIC 165
Strong or too frequently given are the usual subjects of colic. Proba-
bly the most frequent cause of colic is an indigestion of the proteid
of the milk. Either the proteid is in excess or the child has a poor
proteid capacity. Not a few cases of coHc are due secondarily to
defective bowel action. A passage occurs each day, but in too
small amount. There is a continual fecal residue in the intestine
which undergoes decomposition with gas-formation. Cold feet are
often associated with colic. Fright, anger, fatigue, excitement —
any condition, in short, which may make a sufficiently unfavorable
impression upon the child's nervous organism, may produce indi-
gestion and colic.
Likewise any adverse nervous mental state in the mother may
produce colic in the breast baby. Constipation in the mother is
not an infrequent cause.
Treatment. — Repeatedly I have had under my care nursing
babies who suffered from habitual colic and who recovered after
the regulation of the mother's bowels by exercise, diet, and medica-
tion. In other breast cases in which the mother's milk upon re-
peated examination proves too strong and the child suffers daily
from colic, a dilution of the milk may be made by the use of plain
water or barley-water, from one-half ounce to one and one-half
ounces of the diluent being given before each nursing. In addition
to the above, the bowels of the colicky infant should move at
least twice daily, morning and evening. When this does not take
place readily a simple laxative, such as milk of magnesia, one-
half to one teaspoonful, or ten to thirty drops of aromatic cascara
sagrada, may be given daily. Under no condition should a child
subject to colic, be allowed to go without a bowel evacuation for
more than twenty-four hours.
Diet. — The dietetic management of colic in the bottle-fed consists
in adapting the food to the child's digestive capacity. The bottle
baby may have habitual colic moderately and thrive, but he does
it on an imperfectly adapted food. Here, as in the breast-fed, the
condition is usually dependent upon an excessive casein supply or
a diminished casein capacity. The matter of the adjustment of cow's-
milk proteid in indigestion is discussed in detail under Milk Adap-
tation (page 94). It is sufficient to say that the colicky bottle
baby should have long intervals between feedings — usually one-half
hour longer than otherwise allowed. Digestion is slower in many
of these cases, although in other respects they may be healthy
children. In some the indigestion and pain are so severe that a
perfect adaptation of cow's milk is impossible, and some other food
than cow's milk will be required.
Enemas. — The prevention of colic, then, it will be seen, rests
upon a proper adjustment of the food. The immediate attack is
usually best relieved by the use of an enema at 110° F. of a normal
1 66 GASTRO-ENTERIC DISEASES
salt solution or of soapsuds, which, by inducing a movement of the
bowels, allows the gas to escape.
Medication. — A soda mint tablet dissolved in one ounce of hot
water, given in one-teaspoonful doses repeated at five-minute in-
tervals, is sometimes successful. For a child under one year of age
three drops of spts. getheris comp. (Hoffman's anodyne) may be given
in two teaspoonfuls of hot water and repeated at ten-minute inter-
vals. From five to ten drops of gin, when given in three teaspoonfuls
of hot water, may be used, and repeated in from ten to fifteen minutes
if the attack continues.
Hot Applications. — Hot applications to the abdomen are often
grateful to the patient. For this purpose ten drops of turpentine
in one quart of water at 120° F. may be used with benefit. A
flannel is wrung out of the water or the solution and applied over
the abdomen and covered with a dry piece of flannel. The dressing
may be changed every ten or fifteen minutes.
Opium and its derivatives should not be used in the treatment
of colic. It may relieve the pain temporarily, but it aggravates
the condition to which the colic is due.
BOWEL FUNCTION
In order to keep the infant or young child in good physical con-
dition, one free evacuation of the bowels is required once in twenty-
four hours. While two or three evacuations daily in a nursing or
bottle baby may be desirable, this number is not absolutely necessary.
When there are more than four passages in twenty-four hours, it
means that something is wrong with the intestinal tract. This,
however, may not be of such a nature as to require radical means for
its correction. Thus, in many nursing babies who are supplied with
a high-fat breast-milk there may be several thin greenish stools in
twenty-four hours, in spite of which conditio!; the child thrives
satisfactorily. It is well in these cases to attempt to reduce the
fat in the breast-milk by measures suggested elsewhere, but by no
means should the nursing be interdicted if the baby is making a
reasonable gain in weight. The proof of successful nursing is a
thriving child, not the character of the stool. The habit of an
evacuation at a certain time each day is one of the most important
preventives of constipation in an infant. There is a standing order
in every household where I have such a patient, to the effect that
the child is never to be put to bed for the night unless the bowels
have moved during the preceding twentv-four hours. Either a
simple soap-and-water enema or a small glycerin suppository is
employed. The enema is preferred, from four to eight ounces of
the soap- water being used. The suppository is used only when, for
any good reason, the enema is not available. Placing the child
at stool immediately after the morning bottle is one of the means
BOWEL FUNCTION 1 67
of establishing the habit of an evacuation at a definite time each
day. The child soon appreciates the reason for this position and
acts accordingly. This practice may be begun when the child is
five or six months of age.
Defective Bowel Evacuation. — Defective bowel evacuation in
infants and young children is a form of constipation very apt to be
overlooked, and for this reason it is put under an independent head-
ing. As long as an evacuation takes place daily it is supposed to be
sufficient. Even though a passage takes place daily and voluntarily,
if it is dry and comes away in pieces or in hard balls, or is firmly
formed without the moist surfaces caused by the presence of mucus
and water, it is practically certain that the evacuation is not com-
plete and that fecal matter is retained in the intestine. This may
occur at any age, and when the condition persists, there results,
oftentimes, an intestinal toxemia, with the manifestations referred
to under that caption (page 191). The same methods of treatment
are to be followed as suggested in the preceding chapters on consti-
pation for the various ages of infancy and childhood. Usually,
however, in this type of constipation, dietetic measures are sufficient.
Constipation in Nurslings. — There are many nursing infants,
who are thriving and well in every respect, except that they are con-
stipated. There is greatly delayed or no bowel evacuation without
aid. Our first step in the management of these cases is to examine
into the daily life and habits of the mother. A factor in the etiology
of constipation in the infant is constipation in the mother, which,
if relieved by diet or medication, will often relieve the child; or if
not relieved, the subsequent treatment directed toward the child
will be much less effective. Nursing women who drink a great
Meal of tea are apt to be constipated, and their infants likewise.
The nursHngs of mothers who lead indolent lives, taking but httle
exercise, are likewise sufferers from constipation.
Treatment of the Mother. — Errors in the mother's diet and habits
of life must be corrected and the scheme carried out which is re-
commended on page 64.
Having established a proper regime for the mother, the breast-
milk should be examined (page 76). While high proteid may mean
constipation, it is rare, in my observation, to find this a cause. Low
fat, from 1.5 to 2.5 percent, with normal proteid is much oftener
found to be present in these cases.
Often in such cases the fat in the mother's milk may be increased
by the use of some form of alcohol, given with the meals. Wine,
beer, ale, porter, or the liquid malt preparations ma}'^ be given, the .
mother being allowed to make her own selection according to her
taste. The free eating of red meats also increases the fat in the milk.
Several years ago a series of observations were made in the New
York Infant Asylum relating to the effects of diet on breast-milk.
1 68 G ASTRO-ENTERIC DISEASES
It was found that in some cases the fat could be increased from i to
2 percent b}^ the addition of alcohol to the mother's diet. The
value of the various galactagogs on the market depends, in all
probability, upon the alcohol which they contain.
Treatment of the Child. — From the standpoint of nutrition and
as a laxative, a A'^aluable addition to the diet of the constipated
breast-fed infant, when the mother's milk is found weak in fat, is
cow's-milk cream, one-half to one teaspoonful being given before
every second nursing or before every nursing, according to the
age of the child and his capacity for fat digestion. Children during
the early months of life take pure cod-liver oil readily, which, like
cream, may serve the double function of a food and a laxative.
Establishing by careful instruction the habit of an evacuation of the
bowels at a certain time every day, is a valuable measure in all
children.
Drugs. — Drug-giving is rarely necessary in young children and
should be resorted to only when other measures fail. In case drugs
are necessary, those most useful ordinarily are the preparations of
cascara sagrada. The aromatic fluid extract (Parke, Davis & Co.)
is palatable and may be given in sufficient doses to be effective once
or twice daily. The milk of magnesia with equal parts of the
aromatic syrup of rhubarb, given in doses of from one to three tea-
spoonfuls daily, is an agreeable and usually an effective combina-
tion.
Enemata and Suppositories. — The use of water enemata and sup-
positories is not to be advised as a routine measure. The habit of
depending upon them is readily established, the parts by their fre-
quent use become insensitive to stimulation, and in a few weeks
they fail to act. I have had many mothers come to me for the first
time in great distress when this stage was reached. When the
stool is dry and hard and is passed with difficulty, the injection of
two ounces of warm sweet oil at bedtime is of advantage. This is
not with the idea of producing an immediate evacuation, but rather
to act as a lubricant for the evacuation expected the following
morning.
Malted Foods. — It is elsewhere advised that the nursing baby be
given one bottle-feeding daily. The malted proprietary foods are
distinctly laxative to many children. It has long been my custom,
when in a nursing infant a condition of constipation exists which
is not relieved by careful regulation of the mother's diet, to pre-
scribe one feeding of malted milk daily, the food being given usually
in the strength of one teaspoonful to an ounce of water. Some
children will not take it in this strength, as the sweet taste is objec-
tionable. In such cases it may be given weaker at the beginning,
or it ma}^ be given in a milk mixture suitable to the age of the
child; but when used in this way, there should be no addition of
BOWEL FUNCTION 1 69
sugar. Malted milk or Mellin's food may be used in a quantity
equal to that of the sugar.
Massage is a most valuable means of treatment in the constipation
of older children, but in nurslings and in the bottle-fed of tender age,
on account of the restlessness and crying, it is not generally practi-
cable, and to be effective it requires that it should be given only by
those skilled in its use; therefore, unless the case is an extreme one,
and all other measures have failed, massage is not to be employed
in the very young. I have never seen any benefit from the abdominal
manipulations attempted by the mother or nurse.
Treatment of Constipation in the Bottle-fed. — In the bottle-fed,
inactivity of the bowel is more easily managed than in the nurs-
ling, because in the former we are in a better position to adapt
the food to the child's digestive peculiarities. As a rule, consti-
pated bottle babies should have a reasonably high fat — 3.5 to 4
percent — and sugar up to at least 7 percent, but, as with all rules,
this one is open to exceptions, a few of the most obstinate cases
of constipation that have come under my care being those fed on
a very high fat, the constipation being due to fat indigestion. It
is extremely rare to find a child who can digest, day after day, a
milk mixture containing more than 4 percent of cow's-milk fat.
The Proteid. — Cow's-milk casein is probably the most fruitful
factor in causing constipation in bottle-fed babies, nevertheless
it is necessary for the child's nutrition. A considerable reduction,
such as may be obtained by giving a mixture of cream, sugar, and
water, may relieve the constipation, but the child suffers from a nu-
tritional standpoint, and instead of having a constipated baby to
deal with we have a rachitic one, which is much worse. In not
a few instances I have seen malnutrition result from cutting down
the proteid, in the effort to relieve constipation.
The child's growth and development should jnost concern us in
our relations with him, and this should never be subservient to any-
thing else. A child under six months of age will not thrive satis-
factorily on less than i percent of proteid as found in cow's milk.
He is entitled to at least 1.5 percent, and thrives best when this
amount is given. The relief of the constipation can in almost
every instance be accomplished by other means than a too great
reduction in the casein — the most nutritive element in the infant's
food.
Milk given constipated infants should always be raw, as cook-
ing increases its constipating tendency.
Laxative Agents in the Food. — ^The simplest means of treating
constipation in the bottle-fed is by the employment of a laxative
agent in the food, and when such an agent adds to its nutritive
value, it serves a double purpose. Instead of using water as a
diluent, oatmeal-water No. i (see Formulary) may be employed.
I70 GASTROENTERIC DISEASES
The malted proprietary foods, such as MelUn's food, and malted milk
are laxative to most children. Mellin's food is composed largely
of sugar, and therefore it may be used in place of sugar-of-milk or
cane-sugar in the food mixture, and has thus served me well in re-
lieving constipation. In some instances I substitute a feeding of
malted milk once daily for the regular milk food, with from four
to eight ounces of water, the quantity and strength depending,
of course, upon the age of the child.
Drugs and Local Measures. — Dietetic measures should always be
tried before drugs are resorted to, for when drugs are used, we have
to give them in constantly increasing doses, and they soon become
ineffective. One or two teaspoonfuls of milk of magnesia in one
bottle daily may be recommended as a temporary expedient in some
cases. The magnesia may be of service until the condition is con-
trolled by the diet. The aromatic fluidextract of cascara sagrada,
in doses of from fifteen drops to one dram, may be tried if success
does not follow the use of the magnesia.
Water enemata and suppositories should be used only as tem-
porary measures. Orange-juice, two teaspoonfuls, twice daily be-
fore feedings, is worthy of trial and is of antiscorbutic value in
children artificially fed. Sweet oil and the pure cod-liver oil may
also be used in doses of from fifteen drops to a dram, three times
daily after feedings if the patient shows a tendency to rachitis or to
general malnutrition. In the use of the oils, we have their beneficial
effects not only as laxatives but also as aids to nutrition.
Oil Injections. — In case the stool remains hard and dry, in spite
of the above suggestions, an injection of two ounces of warm sweet
oil (page 173) may be given at bedtime every night, not with a
view of inducing a passage at the time, but as a lubricant to the
parts and as a solvent of the hard fecal masses.
Constipation in Older ChMr^n.— Etiology. — Probably the most
potent dietetic factor in causing constipation in children of the
"runabout" age is the use of full milk. Particularly is this apt to
be the case if the milk is boiled. Constipation may be occasioned,
further, by a too great concentration of the food, insufficient volume
being furnished to produce copious evacuations.
Local Treatment. — In a great majority of children the freer feed-
ing following weaning from the breast and bottle relieves the ten-
dency to constipation from which many children suffer during the
earlier months of life. In a small percentage of cases, however,
such relief is not furnished, and the child will require the attention of
a physician. In making the physical examination of a case of this
nature, special care should be directed toward the examination of
the rectum, in order that local causes, such as fissures or hemorrhoids,
may be ehminated. If fissures are present, the child will use every
effort to prevent a bowel movement.
BOWEL FUNCTION 171
Regular Habits. — As a rule, children who are presented for treat-
ment after the second year have not had the benefit of carefully reg-
ulated habits of life, so that our first step is to correct bad habits,
that may have a bearing on the condition, and to teach good ones.
The desirability of establishing in the child the habit of a bowel
evacuation at a certain definite time every day should be impressed
upon the mother or nurse. In order to bring this about, an attempt
should be made to induce a movement of the bowels by voluntary
effort every morning after breakfast. Not a few children are too
busy, too active in their play, to respond to the call of nature when
it comes, and if it can be repressed, they say nothing about it. If
a certain time of the day is selected for the evacuation, and if they
have to remain at stool until it occurs naturally, or by means of a
suppository after fifteen minutes have elapsed, much is accom-
pHshed by this means alone toward establishing the habit.
Diet. — Ultimately, much may be accomplished in these cases by
diet. Foods other than milk may now be given, so that a high-
proteid milk, a milk rich in casein, is not necessary. As it is de-
sirable to continue the use of milk at this age, the following com-
bination of top milk and water may be used instead of full milk. A
quart bottle of cow's milk is allowed to stand at a temperature of be-
tween 40° and 50° F. for five hours, when the top ten ounces are
removed. The skimming is best done with a Chapin dipper (see
Fig. 10, page 83). The ten ounces of top milk are mixed with
twenty ounces of oatmeal gruel or plain boiled water and given as a
drink.
The giving of high-fat mixtures in constipation is sometimes
overdone even in older children. We seldom find a child five years
of age who can digest, day after day, a milk or cream mixture con-
taining over 4 percent of fat. Attacks of acute indigestion and
faulty nutrition are very apt to result when too high a fat is persist-
ently given. In not a few instances I have seen grave malnutrition
result from an attempt to reheve the constipation by high-fat feeding.
It must also be remembered that high-fat mixtures may produce
constipation in children of any age, hard, very hght colored, usually
foul-smelhng stools resulting. By using the top milk, diluted, we
give a sufficient amount of fat and relieve the constipation by re-
moving a considerable percentage of the casein, the usual constipat-
ing element, the percentage of which in the thirty ounces of food,
above referred to, is but one-third that in full milk. Of course, the
nutritive value of the dilution is less than that of full milk, but the
child is now at an age when proteid can be given in other forms
than in the milk.
Diet after the Second Year. — White wheaten bread, wheaten
flour crackers, with full raw milk should form no part of the
dietary of our patients. It is best to give to parents of children we
172 GASTRO-ENTERIC DISEASES
are treating for constipation a list of permissible articles of food
from which they are instructed to make up suitable meals. The
following articles of diet may be allowed children after the second
year:
Animal broths, purees of Hashed chicken.
peas, beans, and lentils. Lamb chops.
Rare roast beef. Soft-boiled eggs.
Rare steak.
Green vegetables, such as :
Peas. Asparagus.
String-beans. Strained stewed tomatoes.
Spinach. Cauliflower, masted.
■ Cereals, as follows (each cooked for three hours) :
Cracked wheat. Hominy.
Oatmeal. Cornmeal.
The cereals may be served with a small amount of milk and sugar, or
better with butter and sugar.
Bran biscuits. Zwieback.
Oatmeal crackers. Whole wheaten bread.
Graham wafers.
Desserts :
Stewed or baked apple. Cornstarch.
Stewed prunes. Plain vanilla ice-cream.
Custard. Junket.
Malted milk may be given as a drink. Six teaspoonfuls of malted
milk in eight ounces of hot water may be given once or twice daily.
An agreeable change in taste of the malted milk may be made by the
addition of a teaspoonful of cocoa. If milk is given as a drink, the
top ten ounces from a quart bottle should be used as described
above, mixed with twenty ounces of boiled water.
A child in fair health after the second year usually thrives best
on three meals daily. If he is delicate or if a fourth meal does not
interfere with the appetite for the other meals, it may be allowed.
The extra meal, however, should be light, and is best given at from
2 to 3 o'clock in the afternoon. For a child suffering from consti-
pation, it may consist of a cup of broth with a graham or oatmeal
cracker. Orange-juice or a scraped raw apple may also be given at
this time. When only three meals are allowed, the orange-juice or
scraped apple should be given in the afternoon about two hours
before the evening meal. The giving of the fruit-juice or the apple
on an empty stomach is a valuable aid in relieving chronic constipa-
BOWElv FUNCTION
'73
tion. These patients should also be encouraged to eat plenty of
butter.
Treatment after the Fifth Year. — Permissible articles for a child
of from five to ten years of age include those mentioned above, with
the addition of dates, figs, raw and cooked fruits, baked and stewed
potatoes, meats, baked and broiled poultry, and fish. The latter
should be served plain without sauce. Plain puddings may also be
allowed. One or two raw apples, an orange or a large peach or
pear, should be given every afternoon. It is not promised that in
a case of chronic constipation the above diet will at once produce
normal bowel movements. The diet must be continued for weeks
in some cases before marked benefit will be observed; in others
the results are very prompt and satisfactory. Enemata and sup-
positories will be necessary at first until the habit of an evacuation
of the bowels at a certain time every day is established.
Drugs. — Drugs also may be of temporary service. The cascara
preparations are the best that we possess for this condition. If the
child can swallow a pill or a tablet, the drug may be given in this form.
The one-grain tablets of cascara may be ordered and the nurse in-
structed to give from one to three or four at bedtime. If the drug
has been properly prepared from the well-seasoned bark, with a rea-
sonable dose, there will be no griping, and the amount given on
succeeding nights may be diminished instead of increased, as is
often necessary with many other laxatives. Its use should not be
continued longer than two weeks. If the daily evacuation habit is
not established at that time, it will not be formed by further drug-
ging. If the pill or tablet cannot be swallowed, then the aromatic
fluidextract of cascara in doses of from one-half dram to one dram
may be given. Castor oil, calomel, or podophylHn should never be
given without other indications than simple constipation. In the
cases in which the stools are soft when passed, but difficult of pass-
age because of deficient peristalsis, the tinctures of nux vomica and
belladonna may be given with benefit, if continued for a considerable
time. A child three years of age ma)^ be given three drops of the
tincture of nux vomica and two drops of the tincture of belladonna
three times daily in pill, capsule, or liquid form. The constipation
which accompanies mucous colitis is referred to under that heading.
Treatment of Obstinate Constipation. — Despite both diet and
drugs, we meet at infrequent intervals cases which, without struc-
tural deformity, resist our every effort. Drugs, attempts at habit-
forming, and diet have been used and failed until only the most
radical measures along these lines furnish relief. In such cases of
obstinate constipation, I use the following means of management.
Laxative drugs are not given.
Diet. — Milk and cream are prohibited except in sufficient amount
to make the morning and evening cereal palatable. For this purpose
174 G ASTRO- ENTERIC DISEASES
not over two ounces of milk are needed. I prefer that cereals be
taken with butter and sugar. Aside from practically cutting ofiF milk
from the diet, the dietetic measures are the same as mentioned above.
Oil Injections. — For this purpose a soft-bulb syringe of four
ounces capacity is ordered. Over the hard-rubber tip is placed a
small sized adult rectal tube or a No. 18 American catheter. The
catheter or tube is cut so that but nine inches remain for use. The
cut end is forced over the small hard-rubber tip of the syringe
(Fig. 19). A fountain syringe is impracticable for this purpose,
as it is soon destroyed by the oil and rendered unfit for use. Be-
sides, sufficient pressure is not produced to force the oil into the
gut even with a high elevation of the bag. The child is placed on his
back or on his left side, preferably in
.^ the Sims position. The syringe is
\.^ filled with oil, the tube is lubri-
%»^,^^fc. Fig. 19.— Bulb Syringe and Cathethr
■^'^S^j^^ FOR Oil Injection.
cated, and passed through the rectum on into the descending
colon. When it has been passed to the full nine inches, as may
readily be done with a little practice, the syringe is emptied
and the tube withdrawn. The irrigation should be given after
the child has been placed in bed for the night. It is our ob-
ject to have the oil retained during the night. If a passage of
the bowels is produced at the time, or if the oil leaks out during the
night, a smaller quantity should be used. In some of my patients
I have been able to use but one ounce. In very few, indeed, does
it cause an evacuation at the time. If there is a tendency to leakage
a napkin should be worn to avoid soiling the bed-linen. If the oil
is simply placed beyond the internal sphincter, it will rarely be
retained during the night, or if retained, the results are by no means
as good as when it is placed in the descending colon. The following
BOWEL FUNCTION I75
morning, after breakfast, the child is placed on the vessel and kept
there until a bowel movement results or until fifteen minutes have
elapsed. In a great many cases in which the constipation has been
obstinate for months, the bowel will at once be evacuated. When
this does not occur in fifteen minutes, a glycerin suppository is in-
serted, which invariably produces an evacuation. This use of the
suppository, according to my observation, can usually be dispensed
with in a very few days; the use of the oil, however, may have to be
continued for several weeks. When the child has had the oil nightly
and an evacuation the next morning without assistance for two
weeks, I direct that the oil be omitted for a night and the effect noted.
If the usual passage occurs after breakfast, the oil is given for five
nights and then again omitted. If the case progresses satisfactorily
the use of the oil is gradually omitted, being given at first every
second night, then every third, fourth, or fifth night, etc. A con-
siderable number of cases have been completely relieved in two
months. In the event of no passage following the omission of the
oil, its use is continued for two weeks longer, when it is again omitted
for a night. To illustrate this point the following case is cited :
Illustrative Case. — A bo}^ three years of age had never had a
bowel evacuation without drugs, soap enemas, or suppositories since
birth, and finally these were no longer effective. The mother,
thoroughly frightened, brought the child to me. Eight months of
diet and the use of the oil were required before he was entirely
well. It is now three months since the local treatment was dis-
continued and the bowel function remains normal.
The diet with the absence of milk must be continued for
months after the patient is apparently well, and he must not be
allowed to pass a single morning without an evacuation at the
usual time. In assuming the management of one of these cases
I explain to the mother or nurse that the treatment is not
pleasant for the child or the attendant, and that it may have to be
persisted in for weeks, and unless she is willing to carry it out to the
end, it would better not be undertaken. I assure her, however,
that with her cooperation, which is usually readily given, the child
will make a complete recovery. Cases that are slow in responding
to treatment, I usually give the additional advantage of abdominal
massage from twenty minutes to one-half hour, before the child is
placed at stool. The massage should be practised by one skilled
in the work.
The above local measures apply particularly to children after
the eighteenth month. They may be used earlier, however, following
out the diet along the lines laid down for bottle-fed children who
suffer from constipation. In very young children a smaller amount
of oil should be used, never more than two ounces, usually one
ounce is all that is required. When the oil treatment is under way,
whatever the age of the patient, laxative drugs should not be given.
176 GASTRO-ENTERIC DISEASES
VOMITING
While vomiting does not constitute a disease in itself, it is a
condition of such frequency in children, and occurs in such widely
varying circumstances, that any work relating to diseases of children
would be incomplete without its consideration.
The most frequent causes of vomiting depend solely upon the
functions of the stomach. When the stomach is overfilled, vomiting
may result. ' When substances sufficiently irritating come in contact
with its Hning mucous membrane, whether they are swallowed as
such or whether produced by some process of fermentation or by
some other change in the stomach contents, they are ejected. When
there is an involvement of an inflammatory nature of the mucous
membrane of the stomach, whether acute or chronic in character,
the stomach becomes intolerant of the blandest of fluids. Another
condition involving the structure of the stomach, but only occasionally
seen in children, is ulceration, which is usually multiple. I have
made autopsies upon four such cases. In them, vomiting was the
prominent, in fact the only, symptom.
Dilatation of the Stomach. — In this condition the food does not
pass into the intestine but remains in the stomach and undergoes
changes which produce sufficient irritation to cause vomiting.
Pyloric Stenosis. — In pyloric stenosis the food is prevented by
the narrow pyloric opening from passing into the intestine; one
feeding follows another, the stomach becomes overloaded, and, b}'
reason of fermentative change in the residue, sufficient irritation
is produced, in connection with the spasmodic contractions of the
stomach peculiar to the condition, to induce vomiting.
Causes Remote from the Stomach .^ — In intestinal obstruction,
whether due to intussusception, volvulus, peritonitis, or impacted
feces, vomiting is an invariable accompaniment, continuing at irreg-
ular intervals until the obstruction is relieved or until the child dies.
The Acute Infectious Diseases. — The exanthemata and lobar
pneumonia are very apt to be ushered in by vomiting if the onset
is sudden and intense. In appendicitis in children, vomiting is
usuall}^ one of the early symptoms; so also in the different forms of
meningitis, vomiting is often an early symptom, and may continue
persistently during the first few days of the illness. In nephritis,
with uremia, vomiting is usually present. Vomiting may be caused
by fright, by shock, or by a strain of any nature, as in whooping-
cough, or it may be of a purely nervous origin.
Illustrative Case. — A few years ago I had a most unusual and in-
teresting case. The patient was a girl four years old, pale and thin.
The history was that of vomiting for more than a year, which had
begun with rather a protracted, badly managed attack of indigestion.
At first there would be but one or two attacks a day. lyater they
ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 1 77
became more frequent, and for a few weeks before coming to me, the
vomiting had occurred at the table with nearly every meal, before
the meal was completed. The mother was most anxious and appre-
hensive regarding the child's condition. She was always with her,
always fed her, and always worried constantly throughout the meal,
fearing an attack of vomiting. Using the most thorough means of ex-
amination of the stomach, I failed to find anything wrong with it.
After observing the case for some days it occurred to me that the
presence of the apprehensive mother, in whose mind the condition
of the child and the vomiting were uppermost, might be a factor in
causing the vomiting. I accordingly directed that the child take her
meals in the kitchen with the maid, and that the matter of
vomiting should not be mentioned. The mother was directed not
to come in contact with the child in any way during the meal. I
was much gratified and not a little surprised when the vomiting
promptly ceased. After a few months of dining with the maid the
latter was taken ill, and the mother for one day attended to the
feeding. Again the child vomited as before.
The management of the different types of vomiting will be
referred to in the consideration of the various diseases with which
it- is associated.
ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION
Not a little confusion exists as to the differentiation of acute
gastritis and acute gastric indigestion. Cases of gastric indigestion
are often diagnosed as gastritis. In fact, acute gastritis in children
is a very rare condition, while acute gastric indigestion is very
common. Acute gastritis in the young is usually due to the ingestion
of drugs, corrosive or irritant in character. Food given, unsuitable
in character or quantity, or food which may have undergone chemical
or bacterial change, may produce pronounced vomiting, usually
transient in character. Inflammation of the mucous membrane of
the stomach may be produced in this way, but according to autopsy
findings it is most unusual. Acute gastric indigestion is manifested
in sudden repeated vomiting, often with fever, and always with
prostration.
Cases of persistent vomiting which are often diagnosed as gas-
tritis not infrequently prove to be of cerebral or uremic origin, or
they are due to some form of intestinal obstruction.
Autopsies on infants dying from acute gastro-enteric diseases,
such as cholera infantum, rarely show any stomach lesion, although
there may have been persistent vomiting for two or three days.
Treatment. — A high enema should always be given as the initial
treatment in any illness of any nature in which there is acute vom-
iting with an absence of free bowel action. If the vomiting is
continued, the management of the case, regardless of the exciting
1 78 GASTRO-ENTERIC DISEASES
cause, is to wash out the stomach at least once and to give no food by-
mouth. If the case is of more than twelve hours' duration in infants
and twenty-four hours' in older children, colon flushings should be
carried out to supply fluids to the organism (page 199).
Diet. — After twelve or twenty-four hours' abstinence from food,
small quantities of water may be given tentatively, if the child
craves it, or some very weak food. Whey, milk, barley-water, weak
tea, chicken or mutton broth, may be tried in teaspoonful doses
every half hour. Usually cold foods will be retained better than
those that are heated. If the food or water is rejected a further
stomach rest of from eight to twelve hours may be ordered, before
the feeding is resumed.
Treatment of Protracted Cases. — In the protracted cases the
stomach should be washed, at least once daily, with a 5 percent
solution of bicarbonate of soda. It is never wise, in the event of
vomiting, to attempt forced feeding, as nothing will be gained; in
fact, the vomiting may be continued indefinitely, and chronic gastric
indigestion estabHshed, as a result of injudicious attempts at feeding.
For the persistent vomiting of infants, gavage (page 135) may also
be used. I have employed this successfully in a great many cases
of persistent gastric indigestion with vomiting. A food which is
rejected when swallowed, will oftentimes be retained when put into
the stomach through a tube. If nourishment cannot be retained
after thirty-six hours, when given by the natural method or by
gavage, it is best to begin feeding by the bowel, using completely
peptonized milk, at intervals of from six to eight hours, in quantities
of from two to four ounces for young infants and from six to twelve
ounces for children from eight to ten years of age. Applications of
heat or counter-irritation over the stomach area have been of very
little service. I have used mustard leaves from time to time, but
have never been impressed with their value. Drugs were better
omitted. I have treated hundreds of these cases of acute indigestion
with different means of medication, including calomel, small doses of
ipecac, oxalate of cerium, opium, etc., and have been far more
impressed with their uselessness than with their beneficial influence.
Drugs oftentimes get credit to which they are not entitled for the
improvement of the patient. A child has an acute attack of indiges-
tion with repeated vomiting. He is, perhaps, given an enema, his
food is stopped, a certain drug is given in small quantities of water,
and he recovers, and the drug gets the credit. He probably would
have recovered more quickly without the drug. As a rule, drugs,
or even the use of a small quantity of water, when given early, will
prolong the attack.
An enema, the recumbent position, and abstinence from food,
with fluids such as normal salt solution, or nourishment by the
bowel, have given me my best results. When the child craves food,
CHRONIC GASTRIC INDIGESTION; CHRONIC GASTRITIS 1 79
and asks for water after an abstinence of several hours, it may be
tried, but the fact that he asks for it is by no means a guarantee that
it will be retained.
Treatment of Persistent Vomiting. — In pronounced, persistent
vomiting, morphin hypodermatically may be required. The morphin
should be guarded by atropin and given in doses of -L ^q _i__ grain for
a child one year old, to y^ of a grain for a child of from eight to
twelve years old. The relation of the dose of morphin to that of
the atropin should be as i to 2^^. Thus, a child who is given 3^^
grain morphin should have combined with it -g^Q^ grain atropin;
with ^ij grain morphin there should be ^j)^ grain atropin.
It will rarely be necessary to repeat the morphin more than once,
two injections being given at intervals of from four to six hours.
In all cases the usual feedings must gradually be resumed. After
trying different foods it will soon be learned which will best be re-
tained.
CHRONIC GASTRIC INDIGESTION; CHRONIC GASTRITIS
Chronic gastritis is seen most frequently in comparatively young
children, and is often associated with, or is a cause of, marasmus
and malnutrition. Vomiting and regurgitation of food are the
predominant acute manifestations of the disorder. The condition
is almost invariably a result of slight but persistent errors in feed-
ing— errors too small to make the child violently ill, but sufficient
to keep the stomach in a constant state of unrest.
Treatment. — The management consists in daily stomach-wash-
ings, sometimes for a long period, and an adaptation of the food to
the child's digestive capacity (page 94). 'While there is no one w^ay
of feeding these cases, a food of greatly reduced strength must
always be given, particularly when cow's milk is used. As a rule,
these children have a low-fat capacity; not more than 1.5 percent
can usually be taken. Sugar is also badly borne by many of these
infants and must be given in reduced strength — from 3 to 4 percent
only. Usually the proteids are fairly well taken care of if the func-
tion of the stomach is not compromised by too much fat and sugar.
In children under nine months of age, a wet-nurse may help solve
the problem. In beginning with the wet-nurse, however, the child
should not be allowed to get over one or two ounces at a nursing,
lest the fat in the milk continue the trouble. The remainder of
the feeding is given by the bottle. Granum-water or barley-water
No. I (see page 123) may be used in quantity sufficient to bring up
the amount to the number of ounces required.
Dilatation of the stomach is usually present and motor inactivity
necessitates stomach-washing, which may be required for several
months at gradually increasing intervals. Details of the treatment,
which are largely matters of feeding, would necessitate a repetition
l8o GASTRO-ENTERIC DISEASES
of what has been said in the chapter on Malnutrition, Marasmus,
and Food Adaptation, to which the reader is referred.
LAVAGE-STOMACH-WASHING
To Seibert, of New York, is due the credit of first caUing attention
in this country to the value of stomach-washing. Its use was soon
appreciated by pediatricians generally, and at the present time it
is an indispensable therapeutic measure with those who are actively
engaged in children's hospitals, in out-patient or in private work
among children. In the vomiting of children, whether due to an
acute gastro-enteric infection, a chronic indigestion, or a subacute
attack of chronic gastritis, it is equally valuable. The dangers of
stomach- washing can be said to be practically nil. A colleague a
few years ago, while washing the stomach of a child two years of age,
turned away for a moment, when suddenly the struggling child dis-
connected the tube from the glass connecting-rod and swallowed it.
Attempts at its removal through the bowel were unsuccessful;
gastrostomy was performed, the tube removed, and the child recov-
ered. This is the only accident of any kind I have ever known
during stomach-washing.
The Operation. — For lavage, the child is easiest handled when its
arms are pinned to its sides by a towel passing around the body.
It may rest on its back in a crib, or sit upright on the lap of the
nurse or mother (Fig. 20). The clean left index-finger of the phy-
sician is placed upon the base of the patient's tongue. The tube,
moistened with the fluid to be used in the washing, not with oil, is
passed down over the base of the tongue into the esophagus. It is
practically impossible to pass it into the larynx. I have washed
the stomachs of many hundred children and the introduction of
the tube has never been attended with difficulty. When the tube
has entered the esophagus, it should be passed rapidly into the
stomach. At least nine inches of the tube will be required to
reach the lower portion of the stomach. At first the child will
cough, retch, and become red in the face, but this need cause no
alarm. He will soon cry and begin to breathe regularly. When
the tube is in position, the funnel should be held the length of the
tube, two and one-half to three feet, above the patient's body, and
the water, which should first be boiled, poured into it. At first the
water may remain stationary in the funnel, owing to the pressure
of air in the stomach and the straining of the child. When the
child relaxes or the air escapes, being forced upward through the
water, the water will pass rapidly into the stomach.
The apparatus described under Gavage (page 136, Fig. 17) is
used. It should always be boiled before using. If much mucus is
present, a i percent solution of boric acid or borax may be used.
The amount introduced into the stomach at one time varies
LAVi^GE — STOMACH- WASHING
[8r
with the age of the child. In a baby of one week, one ounce
may be used; at six weeks, two ounces; at six months, from four
to six ounces. It is rarely advisable to introduce more than six
ounces at one time. The fluid is allowed to run into the stomach
and is then siphoned out by lowering the funnel, the process being
Fig. 20. — Lavage.
repeated until the fluid returns perfectly clear. From one to two
pints of water may be necessary to complete the washing.
Indications. — It is rarely necessary to wash the stomach oftener
than twice in twenty-four hours. Ordinarily, in the acute vomit-
ing cases, one washing daily for four or five days will answer. In
cases of chronic indigestion with regurgitation, the washing will be
l82 GASTRO-ENTERIC DISEASES
needed less frequently. Here, once a day, or once every second or
third day, will answer.
The following is frequently the history of a case of chronic indiges-
tion with vomiting: There has been for several weeks, vomiting of
food and mucus, two or three times daily. The stomach was washed,
the child carefully dieted with a plain barley-water or a weak milk
mixture, and no vomiting had occurred for perhaps twelve, twenty-
four, thirty-six, or forty-eight hours, when the regurgitation or
vomiting again commenced as before. In such a case it will soon
be learned how frequently the washings should be repeated in
order to control the vomiting. A recent patient represents my
management: A child six months old suffering from malnutrition
had a history of persistent vomiting after each feeding. A greater
part of the food taken was lost. What was not vomited was digested
imperfectly, as was shown by the stools. The stomach was washed
and a large quantity of thick mucus and curds removed. The child
was placed on a barley-water diet. There was no vomiting for three
feedings and then only a small quantity of barley-water was thrown
off. After three days, with daily washings, the vomiting entirely
subsided. The child was put on a weak milk mixture, one-fifth
milk and four-fifths barley-water, and no vomiting of moment
resulted. The food was carefully strengthened, and although in
two weeks the vomiting had entirely ceased, the washings were
continued at intervals of two or three days for a month, until the
water siphoned out was free from mucus. In severe cases of chronic
indigestion the washings at intervals of two or three days may be
continued with advantage for several months.
It must be remembered that in these chronic cases of indigestion,
the patient is ill through abuse of the stomach — usually because too
strong food has been given, or too much of a suitable food was
given at too frequent intervals. As important, then, as the stom-
ach-washing, is the placing of a child on a food suited to its diges-
tive capacity. Lavage is of Uttle service if the bad feeding continues.
The field of usefulness of lavage is not entirely confined to
vomiting cases. Children with indifferent appetite and limited
food capacity, without vomiting, are often greatly benefited by
it. A story frequently heard in our consulting room is as follows :
Food is taken without relish. The child must be coaxed to eat.
There is loss of appetite, usually the result of improper food or
faulty feeding methods. Some patients are absolutely indifferent
to food; many refuse it altogether. In this class of patients a
stomach-washing once a day will often be followed by a surprising
improvement in the appetite. I know of no better appetizer for
many of these pitiful looking babes. In not a few instances I have
been surprised at the large amount of mucus removed from the stom-
ach of one of these children in whom there had been no vomiting
DILATATION OF THE STOMACH 183
whatever, which teaches us that there may be, in infants, stomach
disorders of considerable importance without vomiting or, in fact,
without any other symptom than loss of appetite and malnutrition.
HEMORRHAGE FROM THE STOMACH; VOMITING OF BLOOD
Excluding hematemesis in the newly born, the vomiting of blood
by infants has been due, in my experience, to ulceration of the
stomach (page 184), to purpura fulminans (Henoch's), or to acciden-
tal causes. In two of my proved cases, extensive ulceration of the
stomach was found at autopsy. A boy six years of age died on the
third day with purpura fulminans. There were profuse hemorrhages
from the stomach, from the mucous surfaces, and under the skin.
Ulceration of the stomach is usually associated with marked gastric
disturbance, such as is seen in gastritis and in the different forms of
malnutrition. Accidental sources include the swallowing of blood,
which may take place as the result of a nasal hemorrhage or from
a blow or fall causing injury to the nose or mouth or from the presence
of a foreign body in one of the nostrils. Injury to the pharynx
also may be followed by hemorrhage sufficient to cause vomiting,
if the blood is swallowed. A case of hematemesis in a well-nourished
breast-fed infant five months of age, gave me a great deal of anxiety.
The vomiting of blood continued for several days without the
slightest evidence as to its source. It occurred two or three times
a day, usually shortly after nursing, the quantity of blood being
especially large after the early morning nursing. There were no
cracks or fissures in the mother's nipples, nor could blood be made
•to exude from any portion of the nipples on reasonably strong pres-
sure. I concluded, nevertheless, that its source must be the breast,
and applied a breast-pump, making use of as strong suction as
possible, and obtained milk with a large mixture of blood. Evi-
dently there had been a rupture of some of the smaller blood-vessels
in the gland behind the nipple. At the first nursing, the child was
very hungr)^ and tugged vigorously at the breast, which doubtless
explains why the early morning vomiting showed the most blood.
DILATATION OF THE STOMACH
In children of any age the stomach capacity may be found
greatly increased. Bottle-fed infants under one year of age furnish
the most of the cases.
In the absence of pyloric stenosis (page 185), the persistent
feeding of too large quantities of food is the cause. It is not at
all infrequent, in cases of malnutrition and athrepsia, to find the
patients taking at every feeding from two to three ounces above
the normal stomach capacity for children of their size and weight.
Infants with dilated stomachs almost invariably suffer from in-
digestion, usually with the vomiting of milk curds and mucus.
1 84 GASTRO-ENTERIC DISEASES
the vomiting generally taking place a considerable time after the
feeding.
Oftentimes, in these cases, the nourishment that has been given
is of the proper strength, and all that will be required is to reduce
the quantity allowed and perhaps increase the frequency of the
feedings. The stomach should be washed daily, if the child resists
the simple reduction in the amount of fluid. Particularly is the
stomach to be washed, if there is a tendency to fermentation in
the stomach-contents. The food should contain a low fat and a
moderate amount of sugar. A reasonably high proteid may usually
be given. Because of the tendency to fermentation, these cases
do badly on the gruel diluents also, which, if they have formed a part
of the child's diet, are to be discontinued. Small doses of bismuth
subnitrate — five grains, with two grains bicarbonate of soda, two
hours after each feeding — have a decidedly beneficial effect. Hy-
drochloric acid should not be given and pepsin is unnecessary.
Dilatation of the stomach, after the eighteenth month, will be
found due to the same cause of overfeeding, or the condition may
have been brought forward from earlier infancy. At this age, it is
seen most frequently in children who take large quantities of milk
with their regular meals. Milk being no longer a necessary part of
the diet, it may now be replaced by more concentrated food, such as
meat, eggs, and cereals in moderate amount. Not over four ounces
of fluid should be given with any one meal. The habit of drinking
with meals is best broken by encouraging the child to drink between
meals. One hour before each feeding he should be given eight
ounces of water. It should be given cool, not cold, at a tempera-
ture of from 50° to 60° F., and should be drunk slowly. It is partic-
ularly necessary to give water before the first meal of the day.
ULCERATION OF THE STOMACH
In a large autopsy experience among infants and young children,
I have as yet to see a perforating ulcer, either tuberculous or other-
wise. In fact, aside from those of the newly born I have seen at
autopsy only two cases of ulceration. In three other cases, the
diagnosis of ulceration was made because of hematemesis. In one,
a child one month old, blood was repeatedly vomited. The child
bled to death. At autopsy about two ounces of coagulated blood
were found in the stomach. The mucous membrane of the stomach
was the seat of many ulcers varying in size, but none exceeding
one-sixteenth of an inch in diameter. Another patient, three months
old, had chronic gastro-enteritis with occasional vomiting of blood.
The child died from exhaustion, the autopsy showing multiple small
ulcers in the mucous membrane of the stomach. That ulcerations,
even of a mild degree, play any great part in the digestive disorders
of infants and young children is disproved by the infrequency of
CONGENITAL PYLORIC STENOSIS 1 85
the lesion at autopsy, in children dying from gastro-enteric or
other diseases.
In treating cases of gastric disorders by stomach-washing, it is
comparatively rare that blood is found in the water siphoned off.
At rare intervals the water may be tinged with blood, but the
washings invariably should be continued in spite of this, as I have
never known any hemorrhage of moment to follow. The blood
which appears under these conditions is doubtless from the capil-
laries of the congested mucous surface, distended as a result of strain.
Although such cases are rare, one never knows but that his next
case will be one of them.
Treatment. — In the event of persistent vomiting of blood of
small or large amount which cannot otherwise be accounted for, it
should be regarded as coming from the walls of the stomach. Under
these conditions, food by means of the stomach should be discon-
tinued and the nutrient enema (page 139) should be brought into use.
Bromid and chloral, or stimulants if necessary, may thus be given
with the food. Suprarenal extract in one-grain doses should be
given hourly and continued for twelve hours after the vomiting
ceases. After thirty-six hours water may be given in small amounts,
and the giving of the usual milk mixture diluted one-half, in small
quantities, two or three ounces, may also be commenced. The
normal diet should not be resumed in less than a week, even with
an entire absence of vomiting during this period.
CONGENITAL PYLORIC STENOSIS
In the chapter on persistent vomiting it will be found that
stenosis of the pylorus is mentioned as one of the possible causative
factors of repeated vomiting. The condition of hypertrophy of
the pyloric end of the stomach with narrowing of the outlet is
practically always of congenital origin, even though the symptoms of
vomiting may not appear for three or four weeks after birth.
That a stenosis exists, is suggested by the character of the
vomiting. Two factors are at work in these cases, the spasm and
the stenosis. The time of the occurrence of the vomiting suggests
also the seat of the trouble. Three or four nursings or feedings may
be taken and retained, when suddenly a considerable portion of these
feedings is ejected. The vomiting differs from that of gastric disor-
der, in that it is expulsive, one forcible ejection taking place which
removes all or a portion of the stomach contents. There usually is no
associated diarrhea or other evidence of intestinal involvement, aside
from constipation, this being in marked contrast with the ordinary
acute digestive derangements of infancy. In two hours after feeding,
the stomach of a nursing infant should be practically empty. The
introduction of a stomach-tube in a case of stenosis will show that a
greater part or all of the food is still in the stomach if it has not
1 86 GASTRO-ENTERIC DISEASES
previously been vomited. The "stomach wave" is one of the
characteristic signs of the condition. Beginning at the cardiac end,
the contractions of the stomach produce a wave-Uke movement of
the abdominal wall, as though a ball were moving under it, making a
pressure on the parietes. The ball-like movement is further sug-
gested by the gradual relaxation of the portion of the abdominal
wall first contracted, which leaves the parietes as before. The
contraction continues until the pylorus is reached. Persistent vom-
iting, expulsive in character, in a newly born infant, associated
with scanty, well-digested stools, should always suggest to our mind
the possibility of pyloric stenosis.
Treatment. — The only treatment, in the great majority of in-
stances, is operation. In a gastro-enterostomy, considering the
age of the patient and the usual emaciated condition, the out-
look is not promising, the mortality being necessarily high. A
few cases in which there is but little hypertrophy and moderate
stenosis recover without operation. Before resorting to operation,
there must be the strongest evidence that the child will not recover
without it, as operation should be a last resort. This should be de-
cided as early as possible, before there is a loss of too much strength
and power of resistance. By weighing the stripped patient daily, it
is not difficult satisfactorily to convince ourselves of the advisability
of delay. If the child loses weight day after day, operation by gastro-
enterostomy or divulsion^ should not be delayed. If the weight
is stationary, or if but a slight gain is made, temporizing may be
permitted, with the hope that greater improvement will follow.
The patient should be given the advantage of the best nourishment
possible — human milk. If the mother cannot nurse the patient, a
wet-nurse should be secured. The stomach should be washed at
least once daily to remove the food residue.
PREVENTION OF THE ACUTE INTESTINAL DISEASES
OF SUMMER
Preventive medicine, so called, is at the present time engaging
the attention of the best medical minds. The acute intestinal
diseases of summer, with their large infant mortality, offer a better
field for life-saving measures than does any other department of
pediatrics.
Potent etiologic factors in summer diarrhea are unfavorable
chmate and unfavorable environment. In the class which furnishes
the largest mortality, climate cannot be changed for a sufficient num-
ber to exert any great influence on the general mortality. Through
education the environment may be radically improved, but it can-
not be changed. The hot months come and the tenement child must
^ Dr. Geo. F. Still, of London, who has had considerable experience with
different operative methods, advises divulsion.
PREVENTION OF ACUTE INTESTINAE DISEASES OF SUMMER 187
remain at home. Excursions and outings of various kinds are valu-
able in a small way to comparatively few, as the child must return
to the tenement home at night or after a few days' absence, so that
in our consideration of this class of patients in large cities we must
accept unfavorable environment and hot weather — in other words,
we must treat these cases in their homes. Those more fortunately
situated, who can have the advantage of the country and intelligent
care, are proportionately less liable to diarrheal diseases. Other
than cHmate and environment, the determining etiologic factors
among all classes are: first, a disordered gastro-enteric tract;
second, infected food; third, faulty feeding methods; fourth, an
absence of appreciation on the part of the parents and physicians
of the fact that an attack of diarrhea or vomiting, or even a green
undigested stool, occurring in an infant under eighteen months of
age during the hot weather, is to be looked upon as a serious matter
requiring prompt attention.
Children as well as adults are frequently exposed to disease from
different sources, of which they are ignorant, because their power of
resistance is sufficient for their protection. With milk, the most
readily infected of all nutritional substances, as the chief article of
diet, it may safely be assumed that few infants pass through the
heated term without having been subjected repeatedly to infection
from bacteria sufficient to produce grave illness. An infant's best
safeguard against intestinal infection is a strongly resistant gut,
which is best secured by the absence of digestive disturbances at all
seasons of the year. The summer mortality from intestinal disease
has, thus, a decided bearing upon the feeding, and intelligent man-
agement generally, throughout the year.
Seventeen years ago, at the commencement of my junior service
on the house staff at the Country Branch of the New York Infant
Asylum, I gained my first knowledge of summer diarrhea. While
making rounds early one morning in June, the matter of summer
mortality among the infant population was being discussed with the
resident physician, the late Dr. Clarence E. Kimball. I asked whv
they had such a large summer mortality in an institution situated, as
it was, at a considerable elevation, in the open country, constructed
on the cottage and dormitory plan, with the additional advantage
of good milk, favorable environment, good nursing, and competent
medical attendance. His reply was: "Take your pencil and write
as we go through the wards the names of the children I indicate."
I did so, and, at the completion of the round, he directed me to
keep the list of thirty names, saying that these children probablv
would not survive the summer. Seeking an explanation I remarked
that they were not delicate or athreptic. "No," he replied, "they
look well, but they have foolish, ignorant mothers, and susceptible
intestines. They have had frequent attacks of diarrhea and indiges-
1 88 G ASTRO- ENTERIC DISEASES
tion during the winter and spring. The mothers steal food from
their own table and give it to the children when the orderlies and
nurses are out of the wards. These children have but little intestinal
resistance, and will give us our first fatal diarrheal cases when the
hot weather comes." I kept my list and found that the accuracy of
his prediction was startling. But four of the children named sur-
vived the summer.
Since that time I have had abundant opportunity to observe
that the children who have had frequent attacks of intestinal indiges-
tion during the colder months furnish our severe cases during the
summer. A most important feature, then, in prophylaxis is to
teach the mother how to feed and care for the child all the year round,
and thus, by keeping well, he maintains a high grade of intestinal
resistance.
Etiology. — The principal immediate etiologic factor of the dis-
ease which we have under consideration is an infection of the gastro-
enteric contents by bacteria. The infecting elements are usually
introduced by means of contaminated food and unclean feeding
apparatus.
New York City Conditions and How to Correct Them. — For the
well-to-do, we have high-priced dairies whose product sells at from
fifteen to eighteen cents a quart. For others, we have what is
known as "certified milk," produced under the supervision of a
committee of medical men, which retails at twelve cents a quart.
Obviously, the majority of our infant population are not fed on these
milks. The Straus Laboratories, which supply safe sterilized milk
in New York city, are able to furnish it to but a small proportion of
the tenement population. The other milks, the so-called "market
milks," supply nutrition for an immense majority of the infants of the
poorer classes. These milks have been greatly improved of late
through the efforts of the medical profession and the New York
Health Department; but the matter of the regulation of milk pro-
duction and sale is a large one, and the powers of the authorities are
limited. The majority of our infant population, then, are fed on
milk which, for them, is not a safe food ; and it is among these infants
that the large mortality occurs, and will continue in spite of seashore
visits, daily excursions, and the efforts of the summer corps of
Health Department physicians. It will continue until every large
municipality, such as New York city, shall establish milk depots and
ice stations where safe milk, and ice to keep it safe, may be obtained
at a nominal cost, or free, if the parents are not able to pay for
it. A visiting physician for these people is not absolutely necessary,
nor is a visiting trained nurse, — both are expensive luxuries; but
what is necessary is the appointment for a given district of women
with just plain common sense to teach the uninformed mothers,
who are doing their best according to the light they have, the
PREVENTION OF ACUTE INTESTINAL DISEASES OF SUMMER 1 89
simple details of the infant's care, easily carried out when they know
how, but so rarely done because they do not know how.
Dispensary Rules of Universal Application. — At the out-patient
department of the Babies' Hospital and the New York Polyclinic,
I have had abundant opportunity to come into close contact with
a great many tenement mothers and tenement children. At these
institutions we have a clientele fairly regular in attendance, year
after year; for as one baby after another appears in the family,
they are brought to us for treatment. At these dispensaries we
have a surprisingly low summer diarrhea mortality, because we
teach the mothers how to feed and care for their children all the
year round. They are taught the value of fresh air, the use of
boiled water as a beverage, and the benefits of frequent spongings
on hot days. Both private and dispensary mothers whose children
are under my care are given pamphlets of instruction and also oral
teaching bearing on these points, and particularly as to the care
of the feeding-bottle and the milk. In case special articles of diet
are to be given, they are taught how to prepare them. Written
directions are always given covering the point ; nothing is left to the
memory. Each mother and nurse has it impressed upon her that she
must wash her hands in soap and water before touching the baby's
food or feeding apparatus for any purpose, and that there must be
a covered vessel in which the soiled napkins are to be kept until
w^ashed. At the first sign of intestinal derangement, regardless of
the season of the year, they are taught to stop the milk at once, to
give instead a cereal water, such as barley-water or rice-water, and
a dose of castor oil. It is impressed upon them that, in winter as
well as summer, a green, watery stool means that the baby is ill
and needs treatment. When the mother learns the above lesson for
December, January, and March, she will not forget it in July.
Furthermore, as a result of the immediate correction of a child's di-
gestive disorder during the winter months, we have a much less
fertile field for pathogenic bacteria during the summer.
Prompt Treatment Essential. — Comparatively few cases of in-
testinal diseases have pronounced toxic symptoms at the outset.
At first there are evidences of a mild infection only. There may
be vomiting, with several green, watery stools, with a slight ele-
vation of temperature, or the symptoms may be still more mild
— only one or two loose, green defecations. Prompt treatment
at this time,' even in a crowded tenement, usually means prompt
recovery. When treatment is delayed, when the administration of
milk is continued, severe toxic symptoms and intestinal lesions are
almost invariably the result.
New York City Experiments. ^An interesting demonstration of
what may be accomplished by proper care was made under the direc-
tion of Dr. WilHam H. Park, of the New York Health Department,
I90 GASTRO-ENTERIC DISEASES
during the summer of 1902. Fifty tenement children, ranging from
three to nine months of age, were selected for the experiment. These
children were all fed on the Straus milk. They were visited two or
three times a week by physicians especially assigned to them. The
mothers were carefully instructed as to the care of the milk, the feed-
ing apparatus, and in other necessary details. With the first signs of
illness, the milk was to be stopped, the physician notified, and suit-
able treatment instituted. Among these fifty tenement children, all
under one year of age, all bottle-fed, selected at random, there was
not one death during the summer. This valuable observation bears
out my contention that the deaths of summer diarrhea among
tenement children may be greatly reduced by the use of good milk
given under proper supervision, supplemented by prompt and compe-
tent medical care at the first sign of illness. Perhaps in i percent
of the cases of summer diarrhea a very severe direct infection is
evident, and the condition of the patient very grave from the onset.
In the remainder the invasion is gradual; and, if the warnings are
heeded, the illness will usually terminate quickly in recovery.
How to Secure Good Milk. — To those of my patients of the bet-
ter class who go to the country for the summer, and who have
cows of their own in order to control their milk-supply, I give the
following directions: Before milking, the udders and belly of the
cow should be wiped with a damp cloth to remove clinging par-
ticles of dirt. It is in these droppings containing manure that
the most dangerous forms of bacteria of decomposition enter the
milk. The milker should wash his hands before milking. The
first few jets of milk, coming from the ducts near the openings, are
apt to be swarming with bacteria, and are therefore discarded.
Immediately after the milking, the milk should be strained through
several thicknesses of cheese-cloth, or through absorbent cotton,
into an ordinary milk bottle, which is at once placed in a pail
of cracked ice. Such simple care as this, even on an ordinary farm,
gives a very low bacteria count. As may readily be seen, it is
attended with very little trouble and expense. Different dairies
throughout the country, which are located near my patients for the
summer, meet the above requirements, for which they receive an
extra compensation of five or six cents a quart.
The Necessity for Education. — It will be seen from the foregoing
that the suggestions we have offered are all included under the one
general heading of Education. The mother must be educated how
to live, how to care for the baby, how to clothe him and bathe him
during the summer. It must be impressed upon her that he needs all
the fresh air available. She must be educated to the point of know-
ing what to do at the first sign of threatened disease. Municipalities
must be educated to appreciate their responsibility as factors, nega-
tive or positive, in the summer mortality. The farmer must be
ACUTE GASTRO-ENTERIC INFECTION I91
educated as to how to produce safe milk, and the consumer must be
educated to appreciate its value and pay for it. Above all others,
the physician must be educated along these lines so as to be able
to teach the mothers how to do the right thing as to the care of
her children all the year round.
ACUTE GASTRO-ENTERIC INFECTION; CHOLERA INFANTUM;
GASTRO-ENTERIC INTOXICATION
This form of infection, while acute in character, is rarely of
primary origin. It is usually preceded by a disordered gastro-enteric
digestion. The onset of the urgent symptoms, however, is usually
most pronounced, the child being taken suddenly with persistent
vomiting, retching, and the passing of large watery stools, usually
greenish in color. The prostration is extreme, the respiration be-
comes shallow, the eyes sunken, the skin ashen in color, the pulse
soft and very rapid. The temperature may be high — 105° F. or
106° F. — or it may never rise above the normal. The low-tempera-
ture cases with symptoms of pronounced prostration give us our
most hopeless cases. The system is so overwhelmed by the in-
fection that the patient is unalale to react, I have seen infants die
in twelve hours after the onset of the active symptoms. From this
extreme degree of infection cases vary in severity, to one who is
taken with a sharp attack of vomiting and high fever. Occurring
coincident with or following within a few hours, there are several
large watery stools. The fever soon subsides. The stomach is
washed, the milk is withheld, boiled water or weak barley-water or
rice-water No. i (see formulary) is given, and the child is well in a
day or two.
Treatment. — The management of the case depends entirely upon
the nature and urgency of the symptoms. In the acute choleraic
cases with repeated vomiting, severe toxemia, retching, and profuse
watery stools, stomach-washing and bowel irrigations are useless
procedures. What we must do is to support the patient and aid
him to bear the poison he has to contend with. If the temperature
is high with a dry, hot skin, a cool pack to the trunk, 85° to 90° F.,
which is moistened with water at this temperature every half hour,
will often control the pyrexia. If the feet are cold, hot-water bottles
should be brought into use. If the temperature is below normal,
and the peripheral circulation poor, as indicated by a leaden hue of
the skin, a hot-water bath at 108° F. for five minutes will always
be of service. The bath may be repeated at half-hour intervals.
Other than this, the immediate treatment calls for hypodermic
stimulation and sedatives. The administration by n:outh of food or
stimulants should not be attempted. Tincture of strophanthus and
brandy, hypodermatically, have answered me well in these cases.
Twenty drops of brandy with one drop of the tincture of strophanthus
K;.' C.ASTKo I'NI'l'MvMi' KISIvASIvS
ui;i\' l»f j;'^ '" •'' iiitti \ Ills olOiic, I wo, 1 liicc, oi loiii lioiiis, (l(|Htl<lili^
upon llic iii).;iiu'\ (tl tile i';isc. A ctiiiihiii;!! ion ol iiioipliiii jiiul
;ilii>|>iii iii;i\ l)i- iisid in tiiscs willi pii sisUiit \ ouiil in;;, willi ;i vii-w
((> colli lolling llic- iiltcinpis :il voniiliii^ vvliidi i-xluiusl Uk- patiriit,
Hill :ilst) lo (liniinisli tlir lonl ilMUMls loss of llic lliiids of (lir Ixxly,
lioiii llic icp(,ili(i l;ii);i' watiTv slools. ()l»\ioiisl\ nioipliin should
not l)c i',i\cn iiiiNs'. Iliis condilion exists. I'Oi a child one \cai" of
"K*' r,\\ )'.'■''" "' nioiphin is v;i\c!i with ', ,, i;!ain atiopiii, icpcalcd as
l-c(Hlircd, nut ollciici than once in two lioiiis. Altii the liist \vav
,,',) ^laiii ol iiioiphiii ina\ he i;i\(ii ;is ;iii inilial dose. lUnelicMal
efh'cts fioin the inoiphiii will 1><' luilcd in a diniinntion holh of the
iiiiiiiliei ol stools and ol the \ «iniit iiiv;. In niildi i casis of infcc-tioii,
III which I he \oniilin.i; and llic stools arc less frc(|ncnt, a dilTiiiait
conise is to he pinsiicd. Ill these c;iscn till le should hi" ail ahst iiK'iR-e
fioni food, hoiled walei li(ini', <;i\tii if I he child i-aii retain it. If
\'oinilinj; piisists, the walei should he discontinued. The stomach
should 1k' washed at least once dail\ and the colon inij^aled. If
the iiii!;alion l)iini;s ;iwa\ nincns and fecal niatlei, it shoidd he
icpcalcd, at iiitei\als of fioiii cii^lit to IwcKc lu.nis. The child
shonld iH\ei lie disliiilied foi this piiipose if the iiilestilic coil
limii'S to ciilpiN itsell .it licciiieill illtcixals. A lediictioll ill t he
tcinpcial lite, a ccss.it loll of the \ omit iiiv;, and a diminntioii of the
lilimhci and iiiipio\ement in the ihaiactti of tlu' slools tell lis
whetlui Ol ii.it the CISC is doiu^ wi'll and (k-lcnuiiu' llic fiiillicr
t le.il nieiit , afl( 1 I he iiiit i.il dosi- of oastoi" oil oioaloiiu'l has hciii ^i\cti.
.\s ;i iiile, the iillldi I I \ pe of casi' does liittil wluil calomel is llScd.
if lli( ic is a t( iidcncN to \..iiiit, the oil will laicK \n- ulaiiuil, iinard-
K'SS of how it is >;ivcli. I'loiii ,'- to Z,, i;iaiii of imIoiiuI ni.i\ ])c i;i\cii
at liftecii MiiiMitc intei\als uiilil one i;iaiii is i;i\eii. While slower
in its action, it is iilliiiiatcl\ of moie hciulil than the oil which is
ii'icctcd. Ihiiiii!.; the past sninnui 1 lia\e used a solution of sill
phati- t)f sodi ((dauhci's sail), as aiKocaled h\ Mi. I,. I'. I, a I'clra,
of Niw NOiU, with SMrprisin^l\ i;ood usiilts. ll is will ntaiiicd.
exeii ill llic Ndiiiiliiii; cases, and when v;i\cii in doses of two drams
it piodiices ,1 lice wateiA cNacualioii without tencsmns. 1 nsiialU
picsci ihc it as follows :
l{. Sn.lnsiili.iial.s Sj
Idixiiis siiiipliois ^j
.■Vijim' (|. s, 11(1 \\v
M. ft, suluiii.
,Si^. Two ItMSpuoululs l'\lM\ lIllllV lilillllU'S lllllil llMIl lIuSl'S Ii.ivi-
hirii l.iki'u
When the Nomiliiii,; has siihsidcd, teaspooiifnl doses of |)lain water
or haiU'N' w.ilci, ;;>•"""" \\atei, or rice water should he usi-d al
fiflctMi uiiniitc Ol h.df honi iiiici \ als, and holh incri'ascd as to intcrx'al
and (iiiantitN .is the c.ise inipioxcs. .Mcoliol in the form of hraiidv,
ACUTE GASTRO-ICNTERIC INFECTION I93
a popular treatment, should seldom be used in these cases, and al-
ways well diluted, usually in the food. Vomiting babies should be
given brandy very sparingly or not at all, as it is apt to increase
the irritability of the stomach.
Milk Substitutes. — It is well in using milk substitutes, such as
cereal waters, to use alternately, for the sake of variety, three or
four different preparations. The child will not so soon tire of the
milk substitute as when but one is given and more food will be
taken. It is extremely rare that the substitutes barley, rice, or
granum will not be taken if used in this way, particularly if made
more palatable by the addition of salt and sugar.
The termination of acute intestinal infection is in death, prompt
recovery, or in the development of ileocolitis. The transition to an
ileocolitis in some cases is so sudden that its existence from the onset
is often assumed. That such is not the case is proved by a large
autopsy experience in hospital and institution work, on cases dying
in a day or two from toxemia in which no intestinal lesions of conse-
quence are found. When the diarrhea with loose green mucous
stools continues with fever, it means that an ileocolitis has developed
as a result of the action of the bacteria and the absorption of toxins
by the intestinal mucous membrane.
Drugs. — Unusual care must be exercised in the use of astringent
drugs in the cases we are discussing. I refer particularly to cases that
are mild or moderately severe. It is to be remembered that it is in
the intestinal contents that the trouble exists, and not in the intesti-
nal structure, and that the diarrhea is a conservative attempt on the
part of Nature to protect the intestinal structure. Our first efforts
therefore should not be directed toward stopping the diarrhea, but to-
ward assisting in the ehmination of the intestinal contents — the
source of the illness. The indiscriminate use of opium and astringents
may do irreparable damage in a very short time through a locking
up of the intestine with its bacteria and their toxins, which may be
followed by a sudden rise in temperature, convulsions, coma, and
death. Opium is a most useful drug in diarrhea in children,
but it must be used with caution. When there is tenesmus
with frequent large watery stools, it may be given in small doses
sufficient to control the number and character of the stools with
a view to preventing an excessive loss of fluids from the body.
It should never be given when there are only four or five free
evacuations in twenty-four hours, as in these cases this number
is required to maintain proper drainage. The opium should further
be given independently of other medication so that its use may be
stopped when the excessive number of stools ceases or in the event
of a rise in temperature after it has been given. It would not be
desirable, perhaps, to discontinue the bismuth or other drugs
which may have formed a part of the prescription. In using
13
194 GASTRO-ENTERIC DISEASES
Opium I prefer the Dover's powder, i to ^ grain at intervals of
two or three hours, for a child from six to eighteen months of age.
Bismuth subnitrate in not less than ten-grain doses at two-hour
intervals has given most satisfactory results. In order to be of
service it must produce black stools. In other words, if the bismuth
is not converted into the sulphid in the intestine it apparently is of
no service; if it passes through the bowel unchanged, no favorable
influence will be exerted on the intestinal contents. This occurs
in a small percentage of cases. In such an event the necessary
amount of sulphur is supplied by the use of the precipitated sul-
phur, one grain being added to each dose of the bismuth. A
convenient and agreeable way of giving the bismuth is the following :
I^. Bismuthi subnitratis ov
Syrupi rhei aromatici 5iij
Aquae q. s. ad 5 iv
M. Sig. — One teaspoonful every two hours.
If sulphur is necessary a one-grain powder may be added to each dose
of the bismuth mixture at the time of its administration. In the
same way Dover's powder, if opium is indicated, may be dropped into
the bismuth mixture. The bismuth is continued in the large doses
until the child is ready for milk, when the dose is diminished one-half
and continued until full milk-feeding is permissible or until con-
stipation demands its discontinuance. In using the bismuth in the
large doses advised, it is necessary that the chemically pure drug
be obtained. If free nitric acid or arsenic is present, as is the case
in some of the commercial bismuth on the market, vomiting may
result or symptoms of arsenical poisoning may develop. Irrigation
of the colon (page 207) may be used when there is a tendency to
bowel inactivity with high temperature. With loose watery passages
it is not called for.
Diet. — A difficult problem of no little importance is the nutri-
tion of the patient after the acute symptoms have subsided.
When the temperature has been normal for two or three days, when
the character of the stools improves to such a degree that freer
feeding is to be thought of, unusual care is necessary in order to
avoid a reinfection.
Skimmed Milk. — It must, of course, be our effort to resume
milk-feeding as early as possible, but in resuming milk the amounts
given must be increased very gradually, giving at first only from one-
quarter to one-half ounce of skimmed milk in every second feeding
of the cereal gruel. In not a few cases, even these small amounts
will result in a rise of temperature and a return of the diarrhea.
There are always bacteria remaining in the intestinal tract after an ill-
ness of this nature, which, under the influence of such a favorable
culture-medium as milk take on renewed activity, and the whole ill-
ness may be repeated, perhaps with greater severity than the original
ACUTE GASTRO-ENTERIC INFECTION I95
one, if the milk-feeding is persisted in. I have repeatedly seen in con-
sultation infants who were having what was called a relapse. What
they did have was a reinfection with all the symptoms as severe or
more severe than those of the first infection, and all because of a lack
of appreciation of the necessity of great care in resuming milk. To
avoid mistakes in feeding at this time, as well as early in the disease,
all directions should be carefully written. Nurses and mothers who
think the physicians are over-cautious and pity the hungry child
are very hable to forget oral instructions and give more milk than is
ordered. I always tell these people that when an order is disobeyed
the responsibility is theirs. If the small amount of milk agrees it
may gradually be increased by the addition of one-half ounce to
each feeding every two or three days. Rarely, however, will it
be possible or wise to attempt to give for the remainder of the
summer as strong a food mixture as was taken before the illness.
In milk-feeding at this time super-fat must not be used. Either
full milk or skimmed milk is given. If there is a tendency to relaxa-
tion of the bowels with frequent passages I order skimmed milk to
be used. Whether the food shall be pasteurized, sterihzed, or raw
depends upon the conditions referred to under pasteurization and
sterilization (page iii). Every summer I have infants under my
care who after an attack of diarrhea cannot take even as small an
amount of cow's milk as one-half ounce in each feeding. Not a few
of the marasmic out-patient infants belong to this class. After a
sharp intestinal infection with inability thereafter to take a nutritious
diet, a wet-nurse may be secured for the well-to-do, but the wet-
nurse's milk will not always agree, as I have repeatedly found.
Children who have been very ill with any of the severe forms of
acute intestinal diseases of summer have, as a result, a very weak
fat-capacity, and the wet-nurse's milk, with its 3 or 4 percent of fat in
some instances, produces sufhcient diarrhea to require its discontinu-
ance. When employing the wet-nurse in such cases it is best never
to permit the child to have the full allowance of breast-milk at first.
For a child from three to six months of age, for example, it is wise to
give him two or three ounces of barley-water or a 5 percent milk-sugar
water before each nursing, so that he will be satisfied with two or
three ounces of the breast-milk. When cow's milk cannot be given
and the nurse's milk does not agree, or where for any reason a wet-
nurse is not possible, we are called upon to furnish other means of
nutrition, and this, with our available resources, will not be of a very
high order for infants under one year of age. The animal broths are
of very httle service. They contain but httle nourishment even if
given in considerable quantity. They produce a decided laxative
effect on convalescents from diarrhea. Their only use is in giving
small quantities, an ounce or two added to the gruel to make it more
palatable.
196 GASTRO-ENTERIC DISEASES
Strong starchy foods cannot be digested in sufficient amount
to maintain the nutrition. It is under such conditions that dex-
trinizing processes (page 118) are of considerable service. The
starch is thus converted into mahose, which is readily assimilable.
Here, as in the broth, the relaxing effect of the food on the intestine
may be felt, frequent bowel evacuations being a possible result.
The dextrinizcd gruels, however, are always worthy of trial, and
they have been of considerable service in many cases as a substitute
for cow's milk. When breast-milk is impossible, canned condensed
milk usually answers better than any other means of nutrition. It
is much more easy of digestion than is fresh cow's milk, as is well
known. It is added in small quantities at first to the cereal water
made from barley, rice, or granum. No. i strength being employed.
(See formulary, page 123.) One-half dram may be added to every
second feeding for the first day. The following day this amount
may be added to every feeding. It usually will be well taken and
well digested. It is gradually increased until two, three, or four
drams are added to each feeding. In not a few cases the combina-
tion of condensed milk and cereal diluent must furnish the nourish-
ment for the remainder of the heated term. With the advent of
cooler weather, one ounce of weak cow's milk with the cereal diluent
may be substituted for one of the regular feedings, which later may
gradually be increased one-half or one ounce at a time until the cow's
milk comprises one-third of the food mixture. When this point is
reached an attempt may be made to replace with cow's milk an-
other feeding of the condensed milk. In this way by carefully
watching the case a gradual replacing of the condensed milk
by. fresh cow's-milk feeding may successfully be brought about
until cow's milk only is given.
After the first year, similar methods may be followed if neces-
sary, although at this age cow's milk will usually be tolerated
earlier and other means of feeding than the milk may be brought
into use. Zwieback, bread crusts, and scraped beef — two or three
teaspoonfuls a day — will often be taken without inconvenience
when milk in sufficient amount for proper nutrition disagrees.
At this age the gruels also may be made stronger; No. 2 or No. 3
(see formulary, page 124) will often be well borne. An important
point to be remembered in feeding convalescents from an acute
gastro-enteric disorder is that the food must not be forced, and
that the child must be fed only in accordance with his digestive
capacity. This can best be determined by watching the temperature
and the stools. The gruels as substitute feedings, whether alone or
combined with condensed milk, may be given in quantities equal to
those which the child was accustomed to take in health, but they
may be given at more frequent intervals, never, how'ever, oftener
than every two hours. A child who has been fed at four-hour
ACl'TE ENTERIC INFECTION I97
intervals may take the substitute at three-hour intervals. If fed
at three-hour intervals, he may get the substitute at two or two and
one-half hour intervals. When constipation follows a sharp attack
of diarrhea, an enema must be used not oftener than once in twenty-
four hours. The patient should not be given a laxative unless there
is fever for several days after the acute symptoms have subsided.
ACUTE ENTERIC INFECTION
Acute enteric infection is of two clinical forms and is distinguished
from gastro-enteric infection by the absence of vomiting. As with
gastro-enteric infection, while it may be acute in character, it
can hardly be considered the primary illness, as it is usually pre-
ceded by a latent type of intestinal indigestion. The onset of the
urgent symptoms oftentimes is so sudden and so severe that it is
regarded as the commencement of the illness. The prostration
may be extreme, the temperature high — 105° to 106° F. The
eyes are sunken and the face is drawn and pinched. Convulsions
and muscular twitchings are often present. In institution-infants
I have seen death take place in less than twenty-four hours as a
result of the profound toxemia. The milder forms, characterized
only by a sharp elevation of temperature and moderate prostration,
respond to treatment in a day or two.
Treatment. — As mentioned above, there are two types of infec-
tion, one with diarrhea and one with marked bowel inactivity.
In neither is there vomiting. In both types castor oil, in doses
never less than two drams, is to be given. This is followed by
discontinuance of the milk, whether the patient is bottle-fed or
nursed. As a substitute, barley-water, rice-water, or granum-water
No. I (page 1 24) may be given with salt and sugar added for fla-
voring purposes. An advantage in the treatment of these cases is
that, there being no vomiting, the food is usually well taken
throughout the entire illness, as the patient is ordinarily very
thirsty. With excessive diarrhea the indications for medication are
the same as those given under Acute Gastro-enteric Infection (page
191). Castor oil or sulphate of soda (page 192) is to be used
instead of calomel, at the beginning of the illness.
Intestinal infection with defective bowel action often gives us
our most difficult cases and requires different treatment. In this
type, poisons generated in the intestinal contents seem to be of
such a nature as to cause a partial paralysis of the small intestine,
and it is often with the greatest difficulty that an evacuation
can be induced. So difficult is it, in fact, that the possibility of
an acute peritonitis or an intussusception is thought of by the
physician. It is very necessary to maintain bowel action and to
prevent the accumulation of gas, which by its distention of the
intestine increases the tendency to constipation. Several cases of
198 • GASTRO-ENTERIC DISEASES
this nature with high temperature, sluggish bowel action, and intense
prostration are seen by me every year.
A case in point came under my observation during the past sum-
mer. A female infant nine months of age had been a most difficult
feeding case. In July she was taken with sudden high fever (105°
F.) and convulsions, which were followed by muscle twitchings,
head rolling, and marked prostration. The temperature was uninflu-
enced by local means, although there was no diarrhea or vomiting.
The attending physician, anticipating intestinal infection, gave calo-
mel in divided doses with frequent bowel irrigations. Foul-smell-
ing fecal material came away with the irrigation, but the temperature
and the nervous symptoms persisted; in fact, the condition became
worse. I first saw the child when she had been ill, perhaps ten or
twelve hours, and directed that one-half ounce of castor oil and a
high irrigation of normal salt solution at 80° F. be given. As a result
of the treatment there was one small green movement in addition
to what came away with the irrigation, which was considerable.
The patient was relieved somewhat and the nervous symptoms
measurably subsided, though the temperature still ranged between
104° and 105° F. As a result of the calomel, one and one-half grains
having been given, and the ounce of oil, a free diarrhea was looked for.
It did not appear, however. I then directed that one-half ounce
of castor oil be given daily in addition to the irrigations every eight
hours. This was followed by a slight improvement in the symptoms,
but it required five days of the treatment, one-half ounce of oil and
one grain of calomel being given daily, with abdominal massage,
before the resulting peristalsis was sufficient to relieve the intestine
of its contents. After the establishment of free bowel action, the
child recovered.
A similar case which resulted fatally was seen in consultation.
In this case, a girl eight years old, the toxemia was intense. There
appeared to be almost complete paralysis of the small intestine.
Only small, very foul evacuations could be induced, in spite of the
most active local and internal measures. The child died from
toxemia, before free bowel action could be established.
The management of these cases of the inactive type is partially
illustrated in the histories above given. Our efforts are to be directed
toward supporting the patient by the use of stimulation, hypoder-
mically or by the stomach, and by the use of a non-milk diet, power-
ful laxatives, and frequent colon flushings. Castor oil will often
need to be given repeatedly and should be given freely — at least
one-half ounce every twelve hours — until four or five passages in
twenty-four hours result. While the fever, prostration, and bowel
inactivity persist, it is necessary to continue the irrigations. In
a few cases, apparently better results were secured by using for the
irrigations cold water (70° F. to 80° F.) with the addition of Epsom
salts, one ounce to the pint.
ACUTE ILEOCOLITIS 1 99
Stimulants. — Because of the tendency to convulsions and nervous
irritability, strychnin should not be given. The tincture of strophan-
thus answers better than any other heart stimulant. Alcohol should
be used only under the most urgent conditions of prostration.
If hypodermic stimulation is called for, a combination of tinc-
ture of strophanthus and brandy, or digitalin and brandy, answers
well. For a child six months of age, twenty minims of brandy
with one drop of tincture of strophanthus, or twenty minims of
brandy with 3^^^ grain digitalin, may be given and repeated according
to the requirements of the case — every two hours if necessary.
After the first year, children may be given as much as y^ ^^ grain of
digitalin or two drops of the tincture strophanthus.
Irrigation of the colon (page 207) is now a measure of inestimable
value, both for its immediate local effect and also for increasing gen-
eral peristalsis and thus emptying the small intestine. An increase of
the peristalsis is sometimes well secured by the following procedure :
After the colon is washed with a normal salt solution at a temperature
of 95° F. the tube is introduced as far as possible and eight ounces
of water at 60° F. is allowed to escape. The tube is immediately
removed and an attempt made by elevating the buttocks and press-
ing them together to have the child retain the solution for a few
moments.
In using nutrient enemata and in colon flushings for purposes of
supplying fluids to the circulation we have found that the solution is
best retained when it is introduced warm — at a temperature of about
100° F. The cooler the solution, the more quickly is it expelled
through exciting peristalsis. This fact may be taken advantage
of in these cases of bowel inactivity. After an enema of cool water
peristalsis of the small intestine will often result in the passage of
a considerable quantity of its contents into the colon to be expelled
later with the water. This I have frequently demonstrated. The
action of the cool water will be further assisted by maintaining
light abdominal massage after the tube is removed. Recovery
may follow the clearing out of the intestine, or an ileocolitis may
result, as in gastro-enteric infection. The process of transition
may require but a surprisingly short time, and if recovery is not
prompt an ileocolitis will almost certainly be the outcome.
Upon resuming the milk diet the same precautions relating to
the use of cow's milk must be observed as referred to under Acute
Gastro-enteric Infection (page 194).
ACUTE ILEOCOLITIS.
A great deal of confusion has been occasioned by attempts at
a nomenclature of the acute inflammatory diseases of the intestine
which shall make the clinical aspect of the cases fit the pathologic
findings. Differentiation, ante mortem, into catarrhal, follicular,
200 GASTRO-ENTERIC DISEASES
and ulcerative types is impossible, as has been proved by the care
and daily observation in institution and hospital work of cases
that have later come to autopsy. Consider briefly, for illustration,
the gravest cases, cases which at autopsy show most extensive
ulceration of the intestine. In many of these there was a low
temperature, from ioo° F. to 102° F., and the stools never contained
a particle of blood. In others, in which perhaps considerable blood
was passed for several days, there will be but a mild congestion
of the mucous membrane of the large intestine. Others will con-
tinue for a considerable time, from two to three weeks, with mod-
erate temperature, and die from exhaustion and show nothing at
autopsy but an enlargement of the solitary follicles with areas of
congestion in the lower portion of the small intestine. Recent
work in the bacteriology of the acute intestinal diseases has added
nothing to our knowledge as to the treatment of the condition,
and consequently does not call for discussion here. Acute ileo-
cohtis may be the primary intestinal disease. In this condition
the temperature is usually considerably elevated at the commence-
ment of the illness. After an evacuation of two or three undigested
stools, the passages consist of light-colored mucus, oftentimes streaked
with blood, or they are of green mucus and streaked with blood.
The passages are small, frequent, and attended with considerable
pain and tenesmus. I have repeatedly seen from twenty to thirty
such passages from one patient in twenty-four hours. Far more
frequently, however, this condition follows an acute gastro-enteric
indigestion or an intestinal infection, the dangers of which
were not appreciated, and the case consequently was improperly
treated, the lesions produced being due to the bacteria and their
toxins, which had abundant opportunity to produce pathologic
changes in the intestinal mucous membrane, the extent of which
could only be conjectured during life.
The duration of an ileocolitis is longer than that of any of the
intestinal disorders previously mentioned. With the establishment
of the disease it is rare for a case to recover under ten days. It
oftentimes means an illness of two or three weeks, and sometimes a
longer period must elapse before the usual diet may be resumed.
The temperature range is variable — from normal to 104° F. There
is always emaciation. The degree of prostration is dependent
upon the amount of toxemia, the extent of the lesion, and the man-
agement of the case, particularly as relates to supportive measures
and the nature of the nutrition.
Treatment. — "Slilk is to be stopped at once, whether the patient
is breast-fed or bottle-fed. Barley-water, granum-water, or rice-water
No. I (see formulary, page 124) constitutes the basis of diet for chil-
dren under one year of age. Older children may be given the No.
2 strength. To these carbohydrate foods may be added an ounce
ACUTE ILEOCOLITIS 20l
of chicken or mutton broth, with salt or sugar, to make them more
palatable. It is well, for variety, to make up two or three cereal
preparations and alternate their use. In this way the foods will be
better taken and for longer periods than if but one is prepared. In
this form of substitute feeding, an amount similar to what the
child was accustomed to in health may be given, but the intervals
may be shorter by one-half hour or one hour.
Drugs. — In a large experience with acute colitis in institution and
out-patient work, there has been abundant opportunity to test the
value of different drugs that have been advocated from time to time
for the disease. Drugs which have proved of unquestioned value are
castor oil, calomel, subnitrate of bismuth, and opium. Drugs
which have an occasional application are sulphur and the prepara-
tions of tannin. Constitutional measures, supportive in character,
such as heat and stimulation, are, of course, used when indicated,
as in any severe exhaustive illness. At the commencement of the
attack, two drams of castor oil should be given. If this is not retained,
from one to two grains of calomel should be given in divided doses —
one-quarter grain every hour. Bismuth subnitrate is best given
according to the suggestions on page 194. The prescription calls
for ten-grain doses. If black stools do not follow its administration,
one grain of precipitated sulphur is added to each dose. To be
effective the bismuth must be given in large doses. Two or three
grains at intervals of two or three hours are of no value. In cases
over one year of age, fifteen to twenty grains are frequently given
at two-hour intervals. When there is much pain and tenesmus
with frequent, scanty, mucous stools, opium may be used with
advantage, with a view of controlling the tenesmus and diminishing
the frequency of the stools. Paregoric or Dover's powder is usually
selected for this purpose. Dover's powder is preferred because
of the absence of a disagreeable taste and the convenience of its
administration. It may be added to the bismuth at each dose,
not combined with it in a prescription, for uncombined it may at
once be discontinued or given in smaller doses with a diminution
in the number of the stools.
Careful instructions should be given when prescribing opium.
It is to be given for a definite purpose, to prevent straining and the
frequent passages due to excessive peristalsis. As in acute intes-
tinal infection, particularly if there is temperature, it is not well
to attempt to reduce the number of the stools below four or five
in twenty-four hours, and of course opium is not to be given at all
unless the stools are very frequent. Not a few cases do admirably
under the cereal water diet, castor oil, bismuth, and sulphur. The
amount of opium that will be required in a given case may readily
be determined by carefully watching the character and frequency
of the stools. For children under one year of age, the dosage of
202 GASTRO-ENTERIC DISEASES
Dover's powder is from i to ^ grain at two-hour intervals, not more
than seven doses being given in twenty-four hours. From the
first to the tenth year, the dose ranges from one-half grain to two
grains. Mothers and nurses are to be instructed that when there
is a rise in the temperature or when the child becomes drowsy after
its use the opium is to be discontinued or the dose reduced one-half
— another advantage of giving it independently. The younger the
child, the greater caution to be observed in its use. Tannalbin, in
doses of two grains in infants, and from five to eight grains in older
children, is sometimes of service when there is a tendency to large
watery stools or stools containing large quantities of mucus. This
also may be given at the same time as the bismuth. When heart
stimulants are necessary, the tincture of strophanthus is usually
selected. Digitalis is not well borne by the stomach, and for the
same reason, as well as for its unfavorable effect upon the kidneys,
alcohol should be given with caution. When used, it should be
well diluted and given only temporarily during the urgent period
of acute toxemia. Its prolonged use invariably interferes with the
stomach function.
Hot Applications. — Hot stupes or hot compresses to the abdo-
men are often most grateful to the patient, when there is abdomi-
nal pain and tenesmus. The hot applications should be changed
every fifteen or twenty minutes, never being allowed to become cold.
Colon irrigation should be used at least once in every case of
colitis, normal salt solution being employed at ioo° to 105° F.
The solution should always be used warm, as it has a pronounced
sedative effect in some patients when used in this way. It thus may
fulfil two purposes. Whether the irrigation is repeated or not must
depend upon its effect upon the patient. When he strains against
it and there is no apparent diminution in the number of the stools,
it should not be repeated. Frequently, however, the intestine
remains quiet and the number of passages diminishes, after a warm
irrigation — 105° to 110° F. In such cases it may be repeated twice
daily. In cases in which there is not an active IdowcI action, where
decomposing blood and mucus are removed by the washing, it may
be used once or twice daily. Only in the rarest instances when
there are high fever and delayed bowel action should intestinal irri-
gation be practised oftener than once in twelve hours. This line
of treatment is oftentimes overdone, as is apt to be the case with
any useful measure.
Irrigation should always be used for a definite purpose and
discontinued when that purpose is accomplished. Every year, at
the close of the heated term, I see cases of chronic colitis without
fever which are being irrigated two or three times daily without
any indication for the irrigation other than the mucous stools. Irri-
gations, without question, help to keep up the secretion of mucus,
ACUTE ILEOCOIJTIS 203
for I have repeatedly seen it disappear entirely without other
treatment in a few days after the discontinuance of the irrigation.
The time-honored remedy — the injection of starch and opium —
may be of service in the cases in which there is much tenesmus with
the passage of small amounts of blood-streaked mucus or w'hen
bloody mucus exudes from the rectum. In these cases the principal
lesions are usually located in the sigmoid and rectum. A straight-
pipe, l^iard-rubber syringe answers best for this purpose (Fig. 18).
A starch solution of the strength of one dram of starch to an ounce
of boiled water is used. For infants under one year of age five
drops of the laudanum may be added to two ounces of the starch
solution and repeated at intervals of from six to eight hours. Older
children may be given from eight to twelve drops of the laudanum
with four ounces of the starch solution and repeated in from four
to six hours.
Improvement in the colitis is indicated by a subsidence of
the temperature, a change in the character of the stools from
green or clear mucus with blood and scarcely any odor, to
passages which gradually take on a fecal odor and show the presence
of feces mixed with mucus. When it is felt that the case is under
control, a change of climate is most beneficial. A child who has
had colitis at the seashore or in town, will invariably have its recovery
hastened by a removal inland to the mountains or among the hills,
W'here an open-air life is to be insisted upon.
Diet in Convalescence. — With a subsidence of the fever and an
improvement in the number and character of the stools, the patient's
troubles are not over. The problem of nutrition is often a diffi-
cult one. The child has necessarily been on a reduced diet for
several days, oftentimes for two to three wrecks. If better nutri-
tion than cereal gruels is not soon forthcoming, the patient faces
the danger of malnutrition and marasmus, w'hich is the outcome in
not a few of the badly treated cases in which the disease is not
quickly fatal. The use of milk in some form must sooner or later
be attempted.
Children who have had coHtis bear fat very badly. The
younger the child, the more certain is this the case. This has
been so forcibly impressed upon me that I have discontinued
attempts at feeding these convalescents even with small quantities
of whole milk. I have found that they do best on a carbohydrate
gruel as a basis of diet, to w^hich sugar of milk is added in the pro-
portion of from one-half to one ounce to the pint, thereby furnishing
material for heat and energy. To this sugar-cereal combination,
skimmed milk in small quantities is added, not over one-half ounce,
and that to only one of the feedings, the first day that milk is given.
If this causes no inconvenience an increase of one-half ounce is
made at every second feeding the following day, and an increase
204 GASTRO-ENTERIC DISEASES
of one-half ounce at every feeding the third day. The total quantity
of food given at each feeding is to remain the same, an equal quan-
tity of the cereal diluent being removed to make way for the milk
increase. Thereafter, if all goes well, an increase of one-half ounce
is made in each feeding every day, until the child is taking his daily
feedings of skimmed milk one-half strength. In some cases it may
be found that the child's capacity will be only two ounces of skimmed
milk at a feeding with the cereal water diluent. Here he must
be held, perhaps for a week or two, before milk can safely be advanced.
Usually the younger the child, the more difficult will be the resump-
tion of the milk diet. After the first year the nutrition may be
assisted by a thick gruel, such as No. 2 (see formulary, page 124),
zwieback, bread crusts, or rare scraped beef — two or three teaspoon-
fuls daily. For infants under one year of age who cannot take
even a weak dilution of skimmed milk, one-half to one dram of
condensed milk may be given in the cereal water diluent. A com-
bination of the canned condensed milk and granum No. i (page
124) will usually be well taken. If there is abdominal distention
from starch indigestion, the granum may be dextrinized (page 124).
Barley-water also answers well as a diluent for condensed milk.
In adding canned condensed milk to the cereal water, sugar is to
be omitted. The milk may be increased slowly until from one
to four drams are given at a feeding. Under no considerations,
however, unless we are forced to it, should this diet be permanent.
After from two to four weeks, the use of cow's milk should be at-
tempted, replacing one feeding of the condensed by a small amount
of cow's milk, one-half to one ounce in the customary diluent. To
the cow"s-milk mixture a small amount of cane-sugar, twenty to
thirty grains, should be added, as the child has been accustomed
to the sweet food furnished by the canned condensed milk. Obsti-
nate constipation sometimes follows recovery from severe ileo-
colitis. This is to be managed along the lines laid down for the
management of constipation (page 167). Following an attack
of ileocolitis, the patient must never be allowed to pass twenty-
four hours without an evacuation of the bowels. A standing order
should be given that an enema should be used when this does not
occur.
CHRONIC ILEOCOLITIS
Cases of chronic ileocolitis coming under my care have invari-
ably been preceded by acute attacks, those that were unusually
severe or that were badly managed. These cases represent one of
the forms of malnutrition, but are of such a nature as to require
special consideration. The patient is emaciated, the skin is dry
and rough, the circulation is poor, the extremities are cold, and the
temperature often subnormal, with an occasional sharp rise. The
abdomen is always distended with gas. The stools usually are loose,
CHRONIC ILEOCOLITIS
205
number three to four daily, and contain mucus in considerable
amount. The mucus may be absent for two or three days, when there
will be a rise in temperature to from 102° F. to 105° F., when large
quantities will be passed with a very foul odor. The nervous symp-
toms are usually marked. The child is irritable and sleeps poorly.
In assuming the care of one of these cases it is well to inform
the parents that a rapid improvement is not to be looked for.
A case under my care at the present time, aged three and one-
half years, and which is now making satisfactory progress, weighs
but twenty-three pounds — two pounds less than when she was
eighteen months old. During the first six months that I treated
her, there was very slow improvement, in spite of every advantage
that care and change of climate could afford. The management con-
sists in diet, change of climate when possible, and supportive measures.
It is for the physician to find out in a given case what means of
nutrition is best. These cases vary considerably in their digestive
possibilities, with the exception that they all bear fat foods badly.
Treatment. — Diet. — Chronic colitis is very fatal in young infants
and but few survive. Practically, the only hope for infants under
one year of age is breast-milk, which at first must be given in
small quantities. Sugar-water should be given before the nursing.
These young infants do not do well on starchy foods unless they
have been dextrinized (page 119); when predigested, they may have
too laxative an effect and should be given in small quantities. The
use of starch, therefore, in these cases, for a considerable time at
least, is limited.
For older children, after the first year, skimmed milk, rare scraped
meat, junket, and coddled white of egg or raw egg usually answer best.
In children under one year of age for whom the breast is not
available, the white of egg may be beaten up and given in skimmed
milk or in dextrinized gruel. No. 3 (page 124), if it agrees, or in plain
water with salt added. The whites of two or three eggs may thus
be given daily with benefit. Zwieback or bread crusts may be given
in small quantities. These cases readily develop the alcohol habit,
so that if given at all, its use should not be long continued. The
feedings are necessarily more frequent than in well children. I
usually feed them five times a day — at four-hour intervals.
Enemata. — There should be a standing order for an enema after
every interval of twenty-four hours if no movement from the bowel
takes place during that time. Absence of bowel movement in these
cases almost invariably means fever, prostration, and perhaps convul-
sions. If there is a tendency to constipation, as there will be in some
cases, some laxative, such as magnesia or the aromatic fluidextract
of cascara, should be given daily in sufficient amount to insure at
least one free evacuation.
Irrigation of the colon is not to be used as a routine measure. It
206 GASTRO-ENTERIC DISEASES
is indicated whenever there is a rise in temperature, even though
the bowels moved but a few hours previously. A laxative, prefer-
ably castor oil or calomel, is given also. The further treatment calls
for salt baths, oil inunctions, and the open-air life referred to in the
section on Malnutrition (page 156)
MUCOUS COLITIS
Attention has elsewhere been called to the necessity, in some
of the diseases of children, of ignoring what appears to be a local
manifestation of disease, and treating the patient along dietetic
and hygienic lines. This necessity is in no disease better illustrated
than in mucous colitis, a disease fortunately rare in children, yet
seen with sufficient frequency to warrant our attention. The patients
who have come under my care have invariably been of a pronounced
neurotic type, usually of neurotic ancestry, and invariably from
a neurotic environment.
In children with mucous colitis the appetite is capricious, the
bowels are usually constipated, the child is chronically irritable, and he
is apt to complain of ill-defined pains in the abdomen, which are never
very severe and are not necessarily associated with the taking of
food. There is usually slight generalized pain on pressure. One of
my cases under treatment at the present time, a child four years
of age, — the most pronounced case that I have ever had under my
care, — has never had the slightest evidence of pain on pressure or
otherwise. With the dejections, there is usually mucus in consid-
erable amount, occasionally passed in large masses, at other times
in long tenacious strings, sometimes referred to as "ropy." There
may be several consecutive days in which little or no mucus will
be passed, then large amounts of it will suddenly appear.
The disease rarely follows an acute inflammatory process in the
intestine. In the majority of instances the previous history has
been one of obstinate constipation in a markedly neurotic, underfed
child, the constipation having existed perhaps during his entire life.
Almost without exception the treatment has been by the use of colon
irrigations, using various kinds of astringents, such as solutions of
tannic acid, nitrate of silver, etc.
Treatment. — Local Measures. — The method of treatment to which
these cases most quickly respond is to discard those local measures
which often act as irritants to the intestinal mucous membrane.
Usually as a result of previous treatment and because of the
nature of the disease the constipation is most obstinate. For this
I use the olive oil injection at bedtime, two to three ounces, the
tube being introduced eight inches into the bowel (page 174).
After breakfast on the following morning the child is placed at
stool, and if no passage occurs in fifteen minutes a glycerin sup-
pository is inserted. By this means one passage daily is usually
COLON IRRIGATION 207
insured, and this ordinarily is all that is required. Should this
fail, from one to two drams of the aromatic fluidextract of cas-
cara should be given at bedtime in addition, the medication being
discontinued as soon as it is demonstrated that an evacuation will
occur without it. Local measures other than those suggested for
constipation are not to be employed.
Diet. — Not infrequently these patients have been taking a consid-
erable amount of milk. This is immediately discontinued. In its
place malted milk or whey is given as a drink. The further diet
consists of whole-wheat bread, animal broths, cereals cooked three
hours, eggs, poultry, red meat, stewed fruit, and fruit-juices. Spinach
and asparagus are the only vegetables allowed at the beginning
of the treatment, and these by all means should always be given.
Purees of peas, beans, and lentils are given freely. The use of
butter is also encouraged. I endeavor to have the patient take
three ounces daily. It may be given on bread or on the cereal.
Drugs. — Strychnin and nux vomica appear to exert a very benefi-
cial influence on these cases. The combination of nux vomica and
quinin has been very satisfactory. For a child from five to ten years
of age the following should be ordered:
I^. Tincturae nucis vomicae gtt. xc
Quininge bisulphatis gr. be
M. Div. et ft. capsulae No. xxx.
Sig. — One capsule after each meal.
A child suffering from mucous colitis invariably shows malnu-
trition to a considerable degree. For details as to sleep, rest, exer-
cise, and baths, all of which are more important than medication,
the reader is referred to the section on Tardy Malnutrition (page 158).
COLON IRRIGATION
Colon irrigation was brought prominently into use about fifteen
years ago as a remedy in the intestinal summer disorders of young
children. While unquestionably its usefulness in this respect has
been overestimated, and the irrigation overdone, in selected cases
it is of great service. Because a child has a summer diarrhea,
a colitis, or any disorder of the intestine, it does not follow that
irrigation is indicated, or that he will be benefited thereby. A
child who is having a passage from the bowels every half hour or
hour is not, according to my observation, a fit subject for irrigation.
The colon is kept empty by the active peristalsis and the washing
will remove nothing more than a few shreds of mucus. The cases
benefited by irrigation are those in which peristalsis is not particu-
larly active. When a child is running a temperature of 102° F.
and over, with five or six green mucous passages daily, one or two
colon irrigations a day will unquestionably be of service in removing
the offending material from the intestine.
208
GASTRO-ENTERIC DISEASES
Every year we see a few cases of intestinal infection, particularly
those of a very acute type, in which there is high fever, intense
prostration, and infrequent bowel action. Occasionally we see a
case of this sort in -which there is no movement whatever without
assistance. In such cases colon irrigation is of inestimable value,
and may be used with advantage as often as once in six or eight
hours. The washing, even if properly conducted, is apt to be strongly
objected to by the patient
and should be completed
as soon as possible. Too
frequent irrigations, with
strong medicated solu-
tions, may keep up the
mucous discharge indefi-
nitely. In a few children
the resistance with strain-
ing is so marked and so
continuous that irrigation
is impossible. These are
usually children who, on
account of the excessive
peristalsis, do not require
irrigation.
The irrigation is con-
ducted as follows: Nor-
mal salt solution at 95° F.
is ordinarily used and a
quart usually suffices. If
there is a great deal of
mucus and blood a i per-
cent tannic acid solution
is better. The irrigation
should be continued until
the solution returns clear.
The temperature of the
solution may be varied
with advantage, depend-
ing upon the nature of
the case; thus, in cases
with subnormal temperature and intense prostration, cases of the
so-called "algid " type, the solution at 110° F. will act as a decided
stimulant. It raises~the temperature, improves the pulse and the
general condition of the patient. In cases with high fever — 105° F.
or 106° F. — a cold solution answers better. I have repeatedly used
it as low as 70° F., and have often found that an irrigation with four
pints of water at 70° F. would reduce a temperature three degrees.
Fig. 21.— Colon Irrigation.
INTESTINAL OBSTRUCTION 209
For irrigation, a soft-rubber catheter, No. 18 American, is best,
for the reason that its walls are stiff and the tube does not easily
bend upon itself, as is apt to be the case when an ordinary catheter
is used. Should this occur, the water may escape an inch or two
within the rectum, and obviously be of no service. When the
tube, well lubricated, has been introduced for nine inches, the tip
will have passed into the descending colon, and further introduc-
tion will be of no advantage. In order to be sure that it is in
the colon, gentle palpation over the left side of the abdomen will
enable one readily to locate it. The tube is attached to an ordinary
fountain syringe by passing the distal end over the sinallest rectal
tip, which is a part of the outfit of every fountain syringe. The
bag should be held not over three feet above the child's body.
When the water is allowed to run, the buttocks should be pressed
together, for by so doing we hope to flush the entire large intestine.
If this can be done, the irrigation will be most efficient.
In this connection I would mention a beneficial effect of irriga-
tion, of which we hear but little, viz., the absorption of a portion
of the salt solution by the intestines (page 199). Not a few of the
intestinal cases have a very limited food capacitv. As a result
of the vomiting and very frequent liquid stools, the body is thor-
oughly drained of fluids. In such cases, after the washing is com-
pleted, I endeavor to have the child retain as much as possible of the
normal salt solution. As an aid to this, the child should be placed
on its left side with the buttocks elevated and the tube introduced
well up into the descending colon. The buttocks should be pressed
together so as to assist the child in retaining the water after it has
passed into the bowel. When a half pint or a pint has passed in,
the tube should quickly be withdrawn and the child kept for half
an hour in a recumbent position with the buttocks elevated.
INTESTINAL OBSTRUCTION
Agencies impeding or preventing the normal evacuation of the
bowels may be either congenital — due to a malformation of some
portion of the intestinal tract — or they may be acquired. Congeni-
tal malformation may be found in any portion of the tract, but
it is most frequently seen at or near the outlet or in the region of
the duodenum. Silverman states that 42 percent of the cases of
congenital malformation are in the duodenum. When it occurs at
the outlet, there may be an imperforate anus, or the absence of,
or atresia of, the lower portion of the rectum.
The treatment of this deformity is surgical. The most common
cause of acquired obstruction is intussusception (page 211). Periton-
itis, both acute and chronic, may cause a cessation of bowel action.
Tuberculous peritonitis, through the formation of fibrinous bands and
adhesions, may cause sufficient constriction of the gut to prevent the
14
2IO GASTRO-ENTERIC DISEASES
passage of the intestinal contents. In such cases also, relief is best
furnished by surgical measures. Acute infective peritonitis (page
469), producing a complete cessation of peristalsis, acts indirectly as
a means of preventing the normal passage of the bowel contents.
The infection is usually secondary. Operative procedures may be
attempted, but all of my cases have been fatal. Two were operated
on, as it was feared there might be an intussusception or a volvulus.
In one case peritonitis followed pneumonia, the infection being
due to the pneumococcus.
Strangulated hernia is a condition by no means difficult of diag-
nosis and demands prompt surgical relief.
Illustrative Cases. — Fecal impaction was found in two of my
cases with intestinal obstruction. Both were seen in consultation.
There had been prolonged constipation with insufficient evacuations
owing to neglect on the part of the attendants. The duration of
the condition it is impossible to state, as the children were permitted
to go to the toilet alone, and as both were under five years of age,
but little dependence could be placed upon their testimony. In
both cases enemata and cathartics had been tried in vain. There
was vomiting and slightly distended abdomen. There was no fever
and no marked tenderness on pressure. In my opinion, the vomit-
ing was due chiefly to the medication, for it ceased when drugs
were discontinued. Both children responded to massage and in-
jections of molasses and water. Eight ounces of molasses and
eight ounces of water were introduced by means of a rectal tube
at intervals of four hours. One case was relieved after the second
injection, the other after the fourth. Massage was early brought
into use. This was given for thirty minutes and repeated after
an interval of ninety minutes. The interrupted massage was con-
tinued until an evacuation occurred.
An unusual case of intestinal obstruction was seen in a wretched,
premature infant, five months of age, weighing about seven pounds.
The child had a congenital heart lesion and deformities of the ears.
It was suddenly taken ill with vomiting and the passage was pale
mucus streaked with blood. No tumor could be felt, but a diag-
nosis of intussusception was made and the abdomen opened. At the
site of the obstruction was a Meckel's diverticulum which had twisted
the gut so as to prevent the passage of gas or intestinal contents.
Intra-abdominal tumors, such as sarcoma of the kidney and hydro-
nephrosis, may cause obstruction through pressure on the intestine.
APPENDICITIS
Appendicitis in children is so essentially a disease requiring sur-
gical interference, that little need be said of it here. Inflammation
of the appendix is a more serious condition in the child than in the
adult and less delay in surgical procedure is permissible. There
INTUSSUSCEPTION 2 1 1
is a much greater tendency toward suppuration than in the adult,
because of the presence of a lymphoid structure within the appendix.
Treatment. — Until surgical procedure can be brought into use, the
patient should be kept as quiet as possible in bed. Fluid diet in the
form of diluted milk and gruel should be given. A saline laxative
should be used to keep the bowels open. Citrate of magnesia is palat-
able and is usually well taken by most children. An ice-bag should be
placed over the appendix and kept constantly applied. If for any
reason operation is inadvisable or impossible, the broth and gruel
diet, the ice-bag, and the recumbent position should be continued
until every indication of pain and rigidity of the rectus has disap-
peared. If the patient has the good fortune to recover, a suitable
time should be selected for an interval operation; for a second
attack is very liable to follow and is always more severe than the first,
abscess formation being very probable. Further, the second attack
may occur when the child is otherwise ill, or is away on his vacation
or at school, where the necessary surgical skill cannot be obtained.
INTUSSUSCEPTION
Intussusception is such a distinctly surgical affection that, like
appendicitis, it requires but little notice here. When there are
clinical signs of persistent vomiting with bile-stained vomitus;
when there is marked prostration with low temperature; when
the stools consist largely of white mucus streaked with blood or
perhaps with moderate hemorrhage, all characterized by sudden
and severe onset, whether a tumor is present or not, a surgical
proposition in a great majority of the cases is before us. Of the
fifteen cases I have seen, all but one occurred in well-nourished
nursing babies, in whom there had been no previous illness, other
than constipation. The youngest nursing baby was two weeks
old; the oldest, ten months. The older child was two and one-
half years of age. The high mortality reported by the surgeons — .
from 50 to 80 percent — is due to two factors : the tender age of the
patients and the delayed operation.
The cases seen in consultation and those seen in children's hospi-
tals usually had been treated for something other than intussuscep-
tion. Sometimes such treatment has been continued for several
days. By the time these cases reach the hands of the surgeon, there
may be extensive adhesions, gangrene of the involved portion of the
intestine, and an exhausted child to deal with.
Reduction by Water-pressure. — It is my custom in such cases first
to send for the surgeon and then make one attempt at reduction by
water-pressure: A well oiled catheter. No. 18 American, or a small rec-
tal tube is attached to the small hard-rubber tip of a fountain syringe.
Two quarts of a normal salt solution is placed in the bag, which is
hung at an elevation of four feet above the child's body. The colon,
212 GASTRO-ENTERIC DISEASES
or that part of it below the intussusception, is slowly filled with a
warm salt solution. A small wet towel is tightly wrapped around
the catheter and fairly strong pressure made at the anus by an
assistant in order to prevent the escape of the fluid. With the
child on his back with both hands free, the buttocks are elevated
on a pillow or bed-pan at a plane ten inches above the shoulders.
In the cases in which the tumor is palpable, an attempt is made,
by gentle abdominal manipulation, to reduce the intussusception.
This in two cases I have thus succeeded in doing.
Illustrative Case. — A child two and one-half years of age was
brought to my office at midnight with a history of a severe attack of
colic about 9 o'clock, which was followed by severe attacks of vomiting
and two stools of mucus and blood. Gentle manipulation of the abdo-
men showed a large sausage-shaped tumor, about five inches long, in
the left hypochondrium, which I diagnosed as an intussusception.
The tumor could not be felt by rectal examination. Water-pressure,
as described above, with abdominal manipulation, reduced the intus-
susception in a few minutes. The other case was in a baby nine
months of age. I saw the child in consultation after the intus-
susception had existed for six days. The child was unconscious
and in profound collapse. He was pulseless, but the heart-sounds
could be faintly distinguished by the aid of the stethoscope. The
rectal temperature was 96° F. The abdomen was greatly distended.
The child had been treated for cholera infantum, although, for five
days, nothing but white mucus tinged with blood had been passed.
Palpation revealed a sausage -shaped tumor extending along the
entire left side of the abdomen, which in spite of the abdominal
distention could easily be made out by firm pressure. The child
was unconscious, so that there was no resistance to the examination.
By rectal examination the projection of the involuted gut, which
resembled the cervix uteri, could readily be distinguished. The
condition of the child precluded all chance of surgical relief, and
I hesitated to use water-pressure, fearing that the gut might
be gangrenous and a rupture result, or that there might be
adhesions sufficient to prevent reduction and that the child might
die during the manipulations. I explained the situation to the
parents, who, after considerable urging, consented to a trial being
made. The patient was accordingly given y^ grain of strychnin,
one drop of tincture of strophanthus, and thirty drops of brandy
hypodermatically. The water-pressure was applied in the usual
way, and it was with the greatest surprise and with supreme satis-
faction that I felt the tumor slowly give way, to be followed by
an expulsion of gas and a quantity of very fetid fecal matter. A
hot colon flushing at 110° F. with a normal salt solution was given
a few minutes later. This was all retained, and six hours later
twelve ounces more were given. Hot-water bottles and bags were
placed about the child. He had sufficiently revived in an hour after
FISSURE OF THE ANUS 213
the first colon flushing to be able to swallow diluted brandy and egg-
water, both of which were freely given. A rapid recovery followed.
This case, to me, was interesting in many ways, particularly as it
emphasized what we sometimes see in work among children when
victory is snatched from the jaws of evident defeat — that we should
never cease our efforts so long as life lasts. It is my practice to
make but one attempt at reduction by water-pressure. When
this does not succeed after a five-minute trial, immediate operation
gives the patient his only chance of recovery.
INFLAMMATION OF THE ANUS
An acute painful inflammation of the anus and of the skin sur-
rounding it is frequently seen in children after a diarrhea of some
days' duration. It is also seen in weakly, delicate children without
any marked intestinal disturbance. The inflammation produces
considerable distress during the passage of a stool and is conducive
to constipation, because the child soon dreads to have a bowel
movement and tries to avoid it. The child's nutrition and manage-
ment in general must first be carefully looked after, as suggested
elsewhere (page 166). For the local trouble, the free use of hot
water after each defecation is necessary. This is to be followed
by a generous application of an ointment made as follows:
I^. Ichthyoli 5j
Unguenti aquae rosae oj
Instructions are given that the parts are to be kept covered with
the ointment, by applying it on a piece of old linen which should
be changed every three hours. This treatment is usuallv followed
by prompt relief.
FISSURE OF THE ANUS
Anal fissure is a condition usually seen in quite young children.
I have seen comparatively few cases in those over two years of
age. Rough manipulation may be a cause, which may result from
the unskilled use of the syringe or rectal tube. I have seen one
such case. With very few exceptions, however, the fissure is due
to the stretching of the parts by the passage of large fecal masses,
causing minute lacerations of the mucous membrane wdthin the
anal ring. A good light and gentle separation of the buttocks
will usually bring the laceration into view. There are iew more
painful affections. The vigorous crying preceding and during the
defecations helps the mother to locate the source of the trouble.
Occasionally the fecal mass will be streaked with blood. Caused,
as it is, by constipation, the painful nature of the condition tends
to delayed bowel action, as the child soon learns to dread a movement,
and postpones it until medication or some manipulative means are
employed to induce it.
A few months ago a little girl, twenty months old, was brought
214 GASTRO-ENTERIC DISEASES
to me because she cried and objected to being placed in position
for a bowel evacuation, and cried much harder during the evacua-
tion. The day preceding the visit to my office the mother feared
that the child would have a convulsion, so great was her distress.
Examination of the rectum showed two rather small fissures extend-
ing through the anal mucous membrane.
Treatment. — Diet. — For a prompt repair of the fissures, it is nec-
essary to render the stools soft. This, in the bottle-fed, is often
easily accomplished by the addition of one of the malted foods,
either Mellin's food or malted milk — one or two teaspoonfuls being
added to the regular milk mixture — or one feeding of malted milk
each day may be substituted for one of the regular feedings. It
may be used in the strength of from four to six teaspoonfuls in
eight ounces of milk.
Drugs. — If drugs are necessary or are preferred, one or two tea-
spoonfuls daily of the milk of magnesia given in the milk food will
answer well.
Local Measures. — Proper regulation of the bowel function, while
absolutely necessary for a cure of the laceration, is not of itself suf-
ficient to effect permanent relief. The parts must be thoroughly
washed with warm water and castile soap after each defecation.
After the washing, and at three-hour intervals during the day, 25 per-
cent of ichthyol in zinc ointment should be applied with a clean index-
finger, which is introduced well up into the anal aperture. If the
fissure is a deep one, it will be well to begin the treatment by cocainiz-
ing the parts, using a 3 percent solution of cocain, and then cauterize
with a 50 percent solution of nitrate of silver, which is apphed on a
cotton-tipped probe. Twelve hours later the ichthyol ointment may
be used as in the milder cases. I have yet to see a case which did
not respond to the above treatment if it was faithfully carried out.
THE INTESTINAL PARASITES
The most common of the intestinal parasites found in children
are of three types: Ascaris lumbricoides, or round-worm; the Ox-
yuris vermicularis, or thread-worm; the Taenia, or tape-worm.
Round -worms. — The round- worms, if in considerable number,
may produce colic or constipation, the latter oftentimes alternating
with diarrhea and with nervous disturbance, sometimes of an
urgent character. In the great majority of my cases, however,
no svmptoms whatever were present, and the fact that the child
had parasites in the intestine was first learned when one was found
to have been passed by the rectum. In one of my cases, in a child
three years of age, there had been repeated convulsions. The
mother stated that the child had passed a couple of round-worms
the day before. I gave one-half ounce of castor oil, which was
followed, in one hour, by two grains of santonin. Forty- three
large round-worms were passed during the next twenty-four hours.
THE INTESTINAL PARASITES 215
This is the largest number that I have known to come from one
child. The round-worm is rare in New York city children. I
have seen but three cases. In children who live in the country-
it is of fairly common occurrence.
My treatment is as follows: At bedtime I give from two to
four teaspoonfuls of castor oil. Early the following morning, about
two hours before breakfast, santonin is given. For children under
two years of age, I give one grain; for those from two to four
years of age, one and one-half grains; after the fourth year, two
grains mav be given. It is prescribed in a powder with an equal
quantitv of sugar of milk, or in capsule. If the passage of worms
follows its use, the treatment is repeated in three days, and again in
a week, if worms are passed after the second treatment.
Thread-worms. — Thread-worms or pin-worms are more frequently
seen in city children than are either round-worms or tape-worms.
They produce an irritation and itching about, and a pricking sen-
sation within, the anus which is bitterly complained of after the
child is in bed for the night, the parasites betng particularly active
at this time. If there is any doubt as to their presence, the patient
should receive a full dose of castor oil — at least two teaspoonfuls.
The discharges should be kept for inspection. If the parasites
are present, they will be seen in the form of pieces resembling white
thread, from one-fourth to one-eighth inch in length. They will
usually be found embedded in a considerable quantity of mucus.
Treatment. — Drugs. — Santonin, recommended by some writers as
of service in these cases, has been without the slightest value in my
hands. In fact, the use of drugs of any kind seems to be of very
little service. After the third year, turpentine in one-drop doses is
probably the most valuable internal medication. It may be given
in emulsion or dropped upon sugar.
Rectal Injections. — Local treatment with the infusions of garlic or
quassia must be our principal reliance in the management of these
oftentimes obstinate cases. In patients in whom the worms have
existed for a considerable time, the resulting irritation will cause a
profuse secretion of mucus in the descending colon and sigmoid.
This mucus must be washed out before any direct treatment can
be brought to play upon the parasite. The colon is first irrigated
with a solution of one tablespoonful of borax to a pint of water.
For this purpose a No. 18 American catheter should be used, as in
colon flushings. The tube should be introduced for at least ten
inches. No attempt is made to have the solution retained. The
child is encouraged to bear down and expel the water alongside of the
tube. After the washing is completed, eight ounces of the infusion
of quassia is passed into the colon. To facilitate its retention the
tube is quickly withdrawn, and the child placed on his left side
with the buttocks elevated on a pillow. This position, or at least
the recumbent position, should be maintained for one-half hour
2l6 GASTRO-ENTERIC DISEASES
after the injection is given. A solution of the bichlorid of mercury
I : 10,000 may be used in the same way. For ordinary family use,
however, I consider either the garlic or the quassia much safer and
equally effective. Garlic is particularly effective, but its very dis-
agreeable odor makes its use objectionable in many households, and
therefore I advise it only when other means fail. After the worms
and the evidence of their presence disappear, the treatment should
be continued for a time on alternate days, and then twice a week,
gradually reducing the frequency of the irrigations until they are
no longer required. Few cases recover in less than four weeks,
and in many it will be necessary to continue the treatment for
months. I have never seen a case, however, which did not event-
ually respond to persistent treatment.
The Tape-worm. — The tape-worm may produce symptoms of
disturbed intestinal digestion, such as colicky pain and diarrhea.
Usually, however, the first warning that the child is affected will
be the passage of segments of the worm.
A worm fourteen feet in length was passed, after treatment,
by a little girl four years old. There had never been a symptom
of its presence other than the passage of several of the segments.
The treatment is as follows: At bedtime give one-half ounce
of castor oil. Early the next morning, two hours before breakfast,
give one-half dram of the oleoresin of male-fern (aspidium) in emul-
sion or in capsule. During the day a light fluid diet only is to be
given, such as broth, gruels, and fruit-juices. One treatment with a
good preparation of the male-fern will usually bring away the worm
entire. The head should be carefully searched for with a magni-
fying glass. If it is not found, the treatment should be repeated
after an interval of twenty-four hours.
PROLAPSE OF THE ANUS AND RECTUM
In anal prolapse there is an eversion of the mucous membrane,
a condition often present in constipation and sometimes seen in
diarrheal conditions of the dysenteric type, in which there is apt
to be considerable tenesmus and straining. If the case is neglected,
the prolapse occurring repeatedly for many days in succession in
cases of constipation, or several times a day in the acute intestinal
cases, the sphincter gradually becomes weakened, the prolapse
more pronounced, and sooii a considerable portion of the involuted
rectum appears with each defecation.
Cases of simple eversion are usually relieved by controlling the
diarrhea, or, when due to constipation, by supporting the perineum
■ during defecation. This support is best furnished by wrapping
a considerable quantity of absorbent cotton around the index-finger,
which rests against and supports the perineum. The child should lie
on its back during defecation. The troublesome cases are those due
to constipation in "runabout" children, where the prolapse has been
PROLAPSE OF the; ANUS AND RECTUM 217
repeated every day for several months. Such children usually show
evidence of illness other than the local conditions and the consti-
pation. They are usually underfed and poorly nourished. Many
are rachitic or show the ear-marks of a previous rachitic state.
Operation Contraindicated. — The reduction of the prolapse can
usually be readily effected by pressure on the protruding mass with ab-
sorbent cotton which has been dipped in warm sterilized olive oil.
The only means of permanently curing prolapse of the rectum and
anus, is effectively and at once to prevent the recurrence. Operation
bv removing sections of the mucous membrane, thus narrowing the
rectal outlet, the use of the actual cautery or of nitrate of silver, is
unnecessary according to my observation. Oftentimes such opera-
tions are productive of much harm. They are unnecessary, because
the case will get well with much simpler means; and harmful because
of the pain and the days of discomfort which may follow such pro-
cedures, to say nothing of the dangers of infection and the possibil-
ities of resulting stricture and deformities of the parts.
Treatment. — Hygienic. — In undertaking a case of habitual pro-
lapse of the rectum it is necessary that the child be put in the most
favorable physical condition. As these children are usually consti-
pated, the diet advised for the constipated (page 171) should be
used. If thread- worms are present as a cause, the treatment should
be directed toward their removal. If the child is anemic or rachitic,
means must be employed to bring the physical condition up to the
highest possible standard.
Postural. — When we have properly prepared the patient, by
thus carefully attending to his general condition, we are in a posi-
tion to relieve the prolapse. We begin as follows: At bedtime
introduce into the colon four ounces of warm sweet oil (page 174).
This will rarely cause an evacuation. In case this should happen,
only one or two ounces should be used. The following morning,
after the first meal, the child is placed in a recumbent position
on a bed-pan with the buttocks elevated to a plane at least four
inches higher than the child's shoulders. In order to establish the
habit of a daily evacuation at a proper time, a glycerin suppository,
infant size, is inserted. If an evacuation does not take place
within a few minutes, eight ounces of soap- water should be intro-
duced. After a few days of the suggestion afforded by the prepara-
tion, the position of the patient, together with his natural efforts
toward a movement of the bowels, will render artificial stimulation
unnecessary. The advantages of postural treatment are obvious.
By lessening the abdominal pressure, which is much greater when
the child is in the upright position, much less force is exerted on
the weakened structures, and the patient is in a position in which
the attendant, by suitable perineal support, by pressing the but-
tocks together, may better prevent the prolapse. If the case is
a severe one, the recumbent position for each daily evacuation must
2l8 GASTRO-ENTERIC DISEASES
be continued for six weeks or longer before the defecation is allowed
to occur with the child in the sitting posture. If later the prolapse
is repeated, four weeks more of the postural treatment must be
carried out.
Supplementary. — After the child is apparently cured, the bowel
function must be carefully watched for months ; twenty-four hours
should never pass without a movement. If a laxative is necessary,
as, in a few cases, it will be, two or three teaspoonfuls daily of the milk
of magnesia given in the child's milk affords a satisfactory laxative,
as it produces a soft stool and does not have a pronounced effect
upon intestinal peristalsis.
The child at first may not take kindly to the postural treatment;
but after a reasonable amount of coaxing and bribing, he soon
becomes accustomed to it. I have never had any trouble in hav-
ing the directions carried out, because of the objections of the child.
ISCHIORECTAL ABSCESS
An abscess of this type is occasionally seen in infant asylums,
babies' hospitals, and in out-patient work. It is usually found in
ill-conditioned children. Such an abscess is generally the result of
an infection of the lymph-glands in the neighborhood of the rectum.
As a rule, the abscess is not deeply situated and its cure is easy.
All that is required is a free incision, a daily washing out of
the abscess cavity with a 3 percent solution of hydrogen per-
oxid and packing with sterilized gauze moistened with a satu-
rated solution of boric acid. A layer of gauze, covered with oiled
silk, should cover the dressing to protect the wound from further
infection from the fecal discharges. In case the granulations are
sluggish, as they may be in marasmic infants, the gauze used for
the packing may be saturated with the balsam of Peru.
HEMORRHOIDS
While a comparatively rare condition in children, hemorrhoids
are occasionally seen. Constipation and neglect of cleanliness
appear to have been the cause in most of my cases. The treat-
ment is to relieve the constipation and carefully cleanse the anus
with hot water and soap after each movement of the bowels, after
which an ointment composed of the following ingredients is applied :
I^. Acidi tannici gr. x
Pulveris camphorae gr. v
Ichthyoli 5 iss
Unguenti zinci oxidi q. s. ad oj
The ointment, in addition to its use after an evacuation of the bowels,
should be generously applied to the anus, night and morning, after
washing.
RECTAL POLYPUS. INCONTINENCE OF FECES 219
RECTAL POLYPUS
According to my observation, rectal polypus is a rare condition.
My cases have been three in number and in children between the
ages of five and seven. In all these cases the polypus was discovered
by the mother after the child's evacuation of the bowels. It may
easily be recognized as an oval, deeply congested tumor protruding
from the anal orifice.
In these children there had been slight hemorrhage from time
to time with the evacuations, the feces being streaked with blood.
The polypi, in these cases, were easy of diagnosis, as they were
situated low down on the rectal wall, each with a rather narrow
pedicle. They were readily ligated and removed.
Repeated bleeding from the rectum in apparent health should
always suggest the possibility of a polypoid growth. Hemorrhoids
also are very rare in young children. Pain and tenesmus are early
signs of fissure, so that bleeding from such a source may readily
be accounted for.
INCONTINENCE OF FECES
Incontinence of feces is a normal condition during infancy, control
being established without training during the second year or earlier.
In well-trained infants I have seen the bowel function under perfect
control at the third month. This is unusual, however. Still, with a very
little teaching it may be accomplished at the sixth month. Incontin-
ence of feces in older children occurs during acute inflammatory condi-
tions, particularly when the colon is the seat of the lesion. It may
also be present in asthenic states, as in grave pneumonia, in tvphoid
fever, and in severer types of the exanthemata, and it may occur
accidentally as the result of a fright, shock, or of severe straining.
Incontinence of feces, as a condition independent of the age
element and illness, is of exceedingly unusual occurrence. I have
seen but two cases — both boys, one four and the other seven vears
of age. In both, the condition had persisted for months. The
desire for an evacuation in these cases came with great urgency
and was uncontrollable. There was no diarrhea or evidence of
any intestinal lesion. One was a dispensary patient, the other
was seen in private. Both were wretchedly nourished children,
both had been badly managed and badly fed. Incontinence rarely
occurred at night. During the day, however, it sometimes took place
two and three times. The patients were on a general mixed diet.
The treatment was the removal of green vegetables and fruit from
the diet, allowing only a small amount of starches, such as bread,
potato, and cereals; eggs, meat, fish, skimmed milk, junket, custard,
etc., were given freely. Medically they were given fifteen drops of the
tincture of the muriate of iron in glycerin and water every four hours,
with one grain of Dover's powder and twenty grains of subnitrate of
bismuth (Squibb) three times daily. Both cases recovered com-
pletely, one in three weeks, the other in five.
THE MOUTH, THROAT, AND NOSE
STOMATITIS
The term stomatitis is applied to an inflammation of the mucous
membrane of the mouth. Three types are usually described by
pediatric authors — the catarrhal, the aphthous, and the ulcerative.
This division is perhaps more the result of the habit of copying
from former writers than from clinical observation. Among sev-
eral thousand out-patient, institution, and hospital patients, it
has been my privilege to treat many cases of stomatitis.
There are many cases of catarrhal stomatitis which under treat-
ment go no further; other cases, with or without treatment, go
on to the development of aphthae, or to an ulcerative condition,
or both conditions may be combined. Many cases, when they
appear for treatment, have the so-called aphthous spots already
developed, but the condition described as "catarrhal stomatitis "
is present also. Other cases when they come to us show marked
ulceration, but never without catarrhal symptoms.
The first symptom of a stomatitis is a superficial catarrhal inflam-
mation of the mucous membrane of the mouth. There is a redness
and injection of the gums. If "aphthae" develop, small grayish
plaques appear on the mucous surface of any portion of the buccal
cavity. In mild cases there may be but three or four areas. In
a case of moderate severity the mucous membrane of the gums,
the hard and soft palate, and the inner side of the cheeks will be
studded with ulcerated grayish-white areas, in size from a pinhead
to a split pea. Occasionally the areas coalesce, forming larger
plaques of a serpiginous type.
tjlceration ordinarily does not appear until after the catarrhal con-
dition has been present for at least three or four days. It will first be
noticed as a faint yellow line at the margin of the gum where it joins
the teeth. This is the commencement of what Virchow describes as
"necrobiosis." Ulceration never occurs unless teeth are present. I
have never known a case to go on to ulceration in a baby fed entirely
at the breast. Whether the case remains simply catarrhal, or whether
aphthae or ulceration or both result, certain symptoms are common to
all. There is a marked increase in the flow of saliva, which, in some
cases, may be said to stream from the mouth, running down over
the chin and soiling the clothes. On account of its acid properties
it causes an irritation of the skin, producing an eczema. The mouth
is hot and painful. Fever is present in a slight degree, both when
STOMATITIS 221
the condition is simply catarrhal and when aphthae are present.
There is but little prostration and the child appears but slightly
indisposed. In cases which go on to ulceration, the fever may be
very high. I have frequently seen it at 104° F. or over. In one
case it reached 107° F. No cause except the ulcerative stomatitis
could be found for the fever. Under properly directed treatment,
the child recovered in a few days.
On account of the pain occasioned by drawing on the nipple,
nutrition may be considerably interfered with in these cases. The
child takes the breast or bottle greedily, draws a few times, stops
and begins to cry. If urged to try again, the process is repeated.
The pain appears to be particularly severe when aphthae are present.
The advent of ulceration will be indicated by a change in the breath,
which becomes disgustingly foul. The gums are thick, spongy,
and bleed easily, and in some cases overlap the teeth very early
in the ulcerative stage. If a case has been neglected or improperly
treated, which was the history of not a few of my dispensary
patients, the ulceration was often so extensive that the teeth be-
came loose as a result of the destruction of the gums, and their
removal was necessary. Strong, vigorous children are as suscep-
tible to the disease as are the rachitic, the badly fed, or the generally
delicate.
The cause of the disease is unquestionably an infection, and
there is no doubt that it is contagious. As to the nature of the
infection, positively nothing is known. The combined action of
several varieties of microorganisms is the most plausible explanation,
I have known it to go through an entire family of several children.
Authors are prone to attribute the trouble primarily to mechanical
irritation, such as careless manipulation during the mouth toilet;
but the majority of my cases when they applied for treatment had
never been accustomed to mouth toilets of any kind. The giving
of overheated food is supposed by some to be a causative agent.
If this w^ere the case, 75 percent of the infants among the poorer
classes would never be free from the disease. The food of bottle-
fed children unless carefully watched is almost invariably given
too hot. The disease, however, is not limited to dispensary patients.
I have seen many cases among the well-to-do. Where gross un-
cleanliness is the family habit, the number of cases of stomatitis
will, for obvious reasons, be greater; there are more bacteria to
carry infection. Children whose mouths are carefully cleaned after
each feeding, do not develop stomatitis. To teach that a child's
mouth should not be washed because an indifferent doctor may
fail to instruct the mother or nurse as to how it should be done is
rank heresy. When errors of the mother or nurse occur in per-
forming the various offices for the child, it is my observation that,
nine times out of ten, it is due to the lack of teaching by the careless
222 THE MOUTH, THROAT, AND NOSE
physician. The mouth may be very effectually cleansed without
injuring the mucous membrane in the slightest degree.
Treatment. — Mouth-washing. — When the stomatitis is catarrhal
or aphthous, preventive treatment — the washing of the mouth after
each feeding with a saturated solution of boric acid in boiled water
• — is also curative. A baby's mouth should be washed as follows:
The child is placed on its side or on its stomach, the index-finger
of the mother or nurse being thoroughly wrapped in absorbent
cotton. The finger is then dipped into the solution, and without
expressing the fluid it is placed in the child's mouth. By gentle
pressure upon the gums and cheeks a sufficient amount of the fluid
will be expressed to run out of the mouth and effectually cleanse
it. The washing is assisted by the opposition oft'ered by the child
to the manipulation of the tongue, cheeks, and jaws.
Drugs. — Internal medication is of no value so far as concerns the
stomatitis, except indirectly. If there is a disordered digestive tract,
it should receive attention by diet and saline laxatives. Calomel
should not be given. Whether the condition was catarrhal or
aphthous, I have never found it necessary to use other means than
the free mouth-washing. Astringents and caustics have never
been necessary. The cases usually recover in from four to seven
days, under strict attention to cleanliness as regards the feeding
apparatus in the bottle-fed, or the mother's nipple in the nursling,
together with the free use of the boric acid solution as a mouth-wash.
Feeding. — The food problem is oftentimes a difficult one to deal
with, particularly in nurslings, on account of the pain caused by draw-
ing on the nippie, the child refusing absolutely to nurse. In some
cases it may be necessary to draw the milk with a breast-pump,
and for a day or two feed the baby with a spoon. In the bottle-
fed, spoon-feeding may also be resorted to. The child will take
the nourishment much better if it is given cool. Small pieces of
ice and teaspoonful doses of cold water are taken eagerly.
Treatment after Ulceration. — With the development of ulcera-
tion a change in the management is necessary, both as regards a
mouth-wash and the necessity for internal medication. Among the
local measures hydrogen peroxid as a mouth-wash, one part of a 3
percent solution in two parts of water, used after each feeding, has
given the best results. Such means, however, are rarely necessary
if the case is seen early. I never employ other than the usual
means of cleanliness — the boric acid solution — except in cases that
show a considerable destruction of tissue.
Chlorate of Potash. — In the internal administration of chlorate of
potash we have what is practically a specific in this disease. Its ad-
ministration should be commenced as soon as the condition is recog-
nized. I usually prescribe it in the syrup of raspberry, using one part
of the syrup to two parts of water. For a child under eighteen months
SPRUE; thrush; mycotic stomatitis 223
of age I order two grains at intervals of two or three hours, not
more than ten grains in twenty-four hours. For a child from eigh-
teen months to three years of age, two or three grains at the same
intervals, not more than fifteen grains in twenty-four hours. With
the above dosage it will be necessary, in the average case, to con-
tinue the drug from three to five days. Very often, after the
improvement is well marked, I reduce the dose one-half and con-
tinue it for three or four days longer.
Much has been written as to the danger of the internal use of
chlorate of potash in children, particularly in relation to its effects
upon the kidneys. If the use of the drug in suitable doses were
of special danger in this respect, the free use of the chlorate of potash
and iron mixture, so extensively prescribed in diphtheria in the
pre-antitoxin period, would have been universally condemned.
I have never seen any unpleasant effects from its use when given
in doses of from two to twenty grains daily, and I have used it in
many hundreds of cases of acute inflammatory conditions of the
throat and mouth.
SPRUE; THRUSH; MYCOTIC STOMATITIS
Thrush consists of a parasitic growth which appears on the
mucous membrane of the mouth in young infants. Plant, in his
classification of diseases of the mouth, calls it a fungous growth,
monilia Candida. The disease makes its appearance in the form
of small white masses about the size of a pinhead. The tongue
and the inner side of the cheeks are favorite sites for the growth,
although in severe cases the entire buccal cavity may be studded
with it, causing it to look as though finely curdled milk had been
scattered over the surface. The growth is firmly adherent, and if
removed forcibly, slight bleeding results. It is invariably associated
with uncleanliness, and occurs, as a rule, in weakly and marasmic
nurslings and in the bottle-fed, more frequently in the latter. It
is rarely seen after the sixth month.
In an infant with sprue, there is evidence of much pain and dis-
comfort while nursing or while feeding from a bottle. The disease
is not contagious. The average case may easily be cured in a week,
if the directions for the treatment are carefully carried out. Active
gastro-enteric disturbances, such as vomiting and diarrhea, may be
associated with sprue, but it is not the rule. Time and again I
have seen cases of sprue in which there were absolutelv no other
signs of the disease aside from the characteristic mouth lesions
and the refusal of food.
If the means of prophylaxis, which will be suggested, are used
as the daily routine, the disease will never appear.
Treatment. — If breast-fed, the mother's nipples must be washed
with a saturated solution of boric acid and moistened with alcohol,
224 'f^^ MOUTH, THROAT, AND NOSE
diluted one-half, which is allowed to evaporate before each nursing.
If bottle-fed, the nipple and bottle should be boiled after each nursing,
the nipples turned inside out and scrubbed with borax water — one
ounce of borax to a pint of water. Whether breast-fed or bottle-
fed, the mouth should be washed wath a saturated solution of boric
acid after each nursing. For this purpose a generous amount of
absorbent cotton is loosely wrapped around the clean index-finger
of the mother or nurse. This is placed in the cold solution, and
without pressing out the water the finger is introduced into the
child's mouth, and, in cases of sprue, brought gently in contact
with the diseased parts, first with one side and then with the other,-
being pressed upon the tongue and under the tongue. It is well
to have the child rest on its side or stomach so that the fluid which
is pressed out by the manipulation of the cotton against the cheeks
and javv^s can readilv escape from the mouth. The washing, which
really amounts to an irrigation, can be done in a few seconds, with-
out the slightest danger of abrading the epithelium. In obstinate
cases, the parts may be penciled once a day with a i percent solution
of formalin, in addition to the other treatment.
Internal medication is of no value in sprue except in correcting
any intestinal derangement that may exist, with a view to improv-
ing the general condition. If the bottle or breast is refused, spoon-
feeding for a few days may be necessary, and will hasten a cure.
If the child is nursed, the mother's milk maybe drawn w^ith a breast-
pump (see page 79) or pressed out with the fingers and fed to
the child. The domestic remedy, honey and borax, should not be
used in any of the inflammatory diseases of the mouth in children.
CANCRUM ORIS; NOMA
This disease is unquestionably the work of a specific microbe,
the nature of which is unknown. The site of the disease is usually
the inner side of the cheek ; either one or both sides may be involved.
The gangrenous process usually begins as a small, inflamed, in-
filtrated area in the mucous membrane opposite the teeth. Destruc-
tion of tissue, distinctly localized, follows and extends with great
rapidity, the tissue sloughing away in masses. The parts for
some distance around the ulcer are hard, infiltrated, and discolored,
presenting an inflamed edematous look. After two or three days
a discolored, ecchymosis-hke area w^fl be noticed on the outer side
of the cheek, corresponding in location to the gangrenous process
within. At this point the ulcer soon perforates. The destruction
of tissue continues quite symmetrically around the ulcer until the
whole cheek is destroyed. The gangrenous process not infrequently
involves the bony structure, causing necrosis of the jaw with a
loosening and failing out of the teeth. A symptom which will
never fail, and can never be forgotten by one who has seen even
BEDNAR S APHTH/E 225
one of these cases, is the almost unbearable stench which emanates
from the patient. When the hands or the fingers of the physician
or nurse come in contact with the gangrenous slough, it is well-
nigh impossible to remove or neutraUze the disgusting odor. The
disease usually occurs in weakly, marantic children, who generally
die from exhaustion and sepsis in ten days or two weeks from the
onset of the disease.
Treatment. — The treatment pursued has been the use of free cau-
terization with nitric acid, chemically pure, and disinfectant wet
dressings of bichlorid i : 2000 ; a saturated solution of boric acid ; or
equal parts of alcohol and water. The latter is apparently more effec-
tive in staying the progress of the disease than is either the bichlorid
or the boric acid solution. On account of the rapid evaporation,
it should be applied on two or three layers of hnt and covered with
rubber tissue. Even then it requires very frequent renewals. Hy-
drogen peroxid may be used to cleanse the ulcer, both before and
after perforation. Hemorrhage is rarely a complication. The
disease is usually fatal, even under the best management.
BEDNAR'S APHTHA
What is known as "Bednar's aphthge " is not an aphtha, but
an ulcer. Among the many cases I have seen, not one was in a child
over four months of age. It is most often seen in poorly nourished
children.
The disease, when well developed, consists of a " punched-out "
appearing ulcer which is seen on the hard palate, usually, but not
invariably, at its posterior portion. I have in but one case seen two
ulcers present at the same time — one on either side of the mesial line.
As a rule, the process is limited to one side of the hard palate. All
the cases seen by me were in bottle-fed children, usually those fed
with a long nipple, or those using a "pacifier," a cork-plugged
nipple, or some other sucking apparatus. The cases always
appeared to be due to a prolonged mechanical irritation. The
ulcer caused no other symptoms than interference with feeding.
The patient is usually brought for treatment for this reason.
The child appears lively, but refuses the bottle after an attempt
at nursing. The mother examines the child's mouth, discovers the
ulceration, and brings the child with a story of an inabilitv to
take the bottle. An examination of the mouth shows the presence
of the characteristic ulcer.
Treatment. — As short a nipple as is practicable should be brought
into use, or, what is better, the child may be fed with a spoon for a few
days, for as long as the local irritation is continued improvement is
impossible. The local treatment consists in washing the mouth with
a saturated solution of boric acid (see page 224) after each feeding,
and the application to the ulcer once daily of a 50 percent solution
226 THE MOUTH, THROAT, AND NOSE
of nitrate of silver. This is best accomplished by means of a tooth-
pick, one end of which is wrapped with absorbent cotton, the child
resting on its back on the nurse's lap or on a table. The nurse
holds the child's arms to its side while the physician, with his left
hand, separates the jaws with a spoon or a tongue-depressor, and
with his right, the child being thus under perfect control, the appli-
cation can easily be made. The ulcer should thus be treated daily
for four or five days until it has healed.
FISSURES OF THE LIPS
Deep cracks and fissures in the lips are of quite frequent oc-
currence among out-patient children. Usually the lower lip is
involved, and in many of the cases there will be but one deep fissure
and that about the middle of the lower lip. Marasmic, ill-condi-
tioned children are the most frequent sufferers. The fissures bleed
easily and occasion considerable pain while nursing. As a result,
less food is taken than the child requires. If the fissure is a deep
one, it will be well to apply a 50 percent solution of nitrate of silver
at the commencement of the treatment. This is to be followed
by frequent applications — three or four times daily — of a 25 per-
cent solution of ichthyol. Healing is usually prompt, requiring
but a few days. If the mucous membrane of the lip generally is
dry and fissured, as in cases of prolonged illness with fever, the fre-
quent use of a 5 percent boric acid ointment, made with cold-cream
as a base, will be of material assistance in controlling the condition.
ULCERATIONS AND FISSURES AT THE ANGLE OF THE MOUTH
Ulcerations and fissures at the angle of the mouth are by no
means uncommon in delicate and marasmic infants. While ulcera-
tion in this location is one of the manifestations of congenital
syphilis, such ulcers are not necessarily syphilitic. The condition,
however, is of sufficient importance to require treatment, because
the affection is so painful as to prevent the taking of adequate
nourishment. Painting the fissure with a 25 percent solution of
ichthyol every three hours during the day will insure the prompt
healing of the fissures.
ULCER OF THE FRENUH OF THE TONGUE
An ulceration of the frenum of the tongue, "the tongue bridle,"
is rarely seen in well children. It is rounded, grayish in appearance,
with a slightly raised border. It usually occurs in infants who
are suffering from whooping-cough, bronchitis, or bronchopneu-
monia. It is never seen except in children who have the lower
incisors well through, the ulceration being due to contact of the
frenum with the sharp teeth during the protrusion of the tongue
in coughing. The ulceration may cause some difficulty in nursing;
GEOGRAPHIC TONGUE. TONGUE-TIE 227
it may be necessary to feed the child with a spoon for a day or two ;
the condition is, however, rarely of a serious nature.
The presence of the ulcer is usually discovered by the mother
while attending to the mouth toilet. The application of a 50 per-
cent solution of the nitrate of silver and the use of a saturated
solution of boric acid as a mouth- wash after each feeding will quickly
relieve the condition.
GEOGRAPHIC TONGUE
The condition known as a "geographic tongue" consists of
smooth, distinct, reddish patches on the tongue's surface, the areas
being surrounded by a light grayish, narrow, raised border. T^e
smooth surfaces comprising the involved areas are devoid of epi-
thelium; the borders are composed of hypertrophied papillse which
take on a grayish color, making a distinct framework for the reddish
areas, which are almost always crescentic in shape. This peculiar
marking has given rise to the term "ringworm of the tongue."
Geographic tongue is seen most frequently in children under three
years of age, and occurs as often among the strong and vigorous
as among the delicate and weakly. The condition is usually dis-
covered by the mother, who, with much agitation, brings the child
to the physician. It does not appear to be due to and is usually not
associated with any disturbance of the gastro-enteric tract. The
portion of the tongue which is not involved appears perfectly normal.
Treatment of geographic tongue is unnecessary, as it causes
no symptoms and apparently is independent of any disease. It
is my custom to assure mothers that the condition is of no con-
sequence. It usually disappears in a few months. I have known
a case to last for a year.
TONGUE-TIE
Tongue-tie is a condition caused by the extension of the frenum
forward, nearly if not quite to the tip of the tongue. It interferes
somewhat with nursing if the milk is hard to draw, and interferes
generally with the free action of the tongue.
The treatment consists in dividing the frenum with curved
scissors. The child is wrapped in a large towel binding its arms
to its sides. It is placed on its back on the nurse's lap or on a
table. It is best controlled when supported by the nurse with its
head between the physician's knees. The head can thus be steadied,
leaving both hands free for the operation. A grooved director,
while not necessary, makes the operation safe and easy. The frenum
is fixed in the slit in the broad end of the director which rests against
the tongue. This raises the tongue and puts the frenum on a ten-
sion, and the division with the curved scissors is a simple matter.
Bleeding is usually so slight that it need not be considered.
DISEASES OF THE RESPIRATORY TRACT
TAKING COLD
By "taking cold" we understand that through the influence
of cold there is produced upon some portion of the skin an impres-
sion similar to that of shock. This impression affects the entire
body and manifests itself most frequently in the form of a conges-
tion of the mucous membrane of the respiratory tract, between
which and the skin there seems to be an intimate connection. Micro-
organisms play an important role in the process. They are found
in large numbers on the diseased mucous surfaces. The changes
in the mucous membrane resulting from exposure prepare it for
their growth and development. "Taking cold" means previous
exposure, and what will constitute a sufhcient degree of exposure
in one child may produce no effect in another. According to my
observation the most frequent cause of colds in infancy is the
effect of cold air on a moist skin. The child that perspires readily,
or the child that is made to perspire by unsuitable clothing, suffers
most in this respect, during the cold season.
I look upon inadequate head-covering as a most frequent cause
of diseases of the respiratory tract in the young. Usually in the
countrv during cold weather, an infant is dressed for the daily outing
in a warm room with the temperature ranging from 70° to 80° F.
He is wrapped in ample coats, blankets, and leggings. The child
is active, throws his legs and arms about, and the dressing thus
far having consumed considerable time, he perspires freely, but
still the dressing is not completed. On the head is placed one
of the more or less artistically decorated airy creations which are
sold in the shops as children's caps. They furnish httle protection
for the many square inches of the almost bald little head. The child
is taken out of doors while the wind is blowing and the result is a
cold, and how it came about is never understood! He was supposed
to be dressed ideally for cold weather. The notion is common,
and to a certain extent proper, that a child's head should be kept
cool. This theory, however, gives rise to carelessness as to the
head-dress. During the colder months, as an extra protection, I
advise mothers to make a skull-cap of thin flannel, for the child to
wear under the regular outing cap.
Allowing a child to sit on the floor during the winter months
is probably the next most frequent cause of his taking cold. Kick-
ing off the bedclothes at night is another frequent cause. Taking
ACUTE RHINITIS 229
the child from a warm room through a cold hall is not without
danger. Holding the child for a few moments by an open window
during the cold weather is often followed by croup, bronchitis,
or pneumonia. The uneven temperature of the living-rooms and
sleeping-rooms in many of our apartment homes is a very common
cause of cold. Frequently during the day the temperature will
be between 75° and 80° F., but at night, when the fires are banked,
it falls to 55° or 60° F. or lower. The child went to bed perspiring,
kicked off the bedclothes, the temperature in the room fell, the
body became chilled, and the child took cold. The temperature
of the living-room should range from 70° to 72° F., the sleeping-
room from 66° to 68° F. Of course, it will be impossible to keep
the temperature at all times at these figures, but the closer we
approximate to them, the safer the child will be. In many instances,
colds in infants are attributed to the bath. Among dispensary
mothers this is often considered a cause of cold. I have never
known a cold to be due to a bath, although, of course, when care-
lessly given, such a thing is possible.
Among rachitic and rheumatic children there is a marked pre-
disposition to catarrhal affections; they acquire laryngitis and
bronchitis upon very slight provocation. Adults and "runabout "
children with coughs and colds should not come in contact with
infants. There is undoubtedly an element of contagion in such
cases. It is a very bad practice to have a "family pocket-handker-
chief," The youngest infant is entitled to a handkerchief inde-
pendent of the other children, and one handkerchief should never
do service for more than one individual. Children should not be
allowed to sit on the floor during the winter. They can have their
playthings on the bed, on the sofa, or, for those under one year,
in a clothes-basket which may be raised on two thick pieces of wood
or a couple of books. There is always a draft near the floor. The
"pen" referred to on page 37 is the best scheme that I know of
for keeping children from the floor.
The room in which the child is dressed for an outing should not
be above 70° F., better below it. Securely pinning bed-blankets
to the mattress, or preferably a combination suit with "feet," will
do much to prevent taking cold at night.
ACUTE RHINITIS (CORYZA; SNUFFLES? COLD IN THE HEAD)
Acute rhinitis is a very common ailment throughout childhood.
Newly born babes, "runabouts," and school-children are alike
sufferers. The onset is usually sudden, with sneezing and with diffi-
culty in breathing through the nose. This may continue for a few
hours, in some cases for a day or two, when a mucous, watery, nasal
discharge appears. On account of its interference with nursing,
infants are the greatest sufferers ; breathing, which has to be carried
230 DISEASES OF THE RESPIRATORY TRACT
on largely through the mouth, is difficult, and nursing, in consequence,
frequently interrupted. There may be a degree or two of fever
at the commencement of the attack, but, as a rule, it lasts only a
few hours. Neglected cases sometimes become infected with pyo-
genic bacteria and a troublesome purulent rhinitis results. In
the majority of the neglected cases, however, and in some of those
that are well treated, this is the beginning of an inflammatory pro-
cess which involves successively the fauces, tonsils, larynx, and
bronchi. Repeated attacks doubtless aid in the production of adenoid
growths in the nasopharyngeal vault.
Differential Diagnosis. — Acute simple rhinitis is to be differen-
tiated from specific rhinitis, which, as is well known, is one of the first
manifestations of congenital syphilis. When due to syphilitic infec-
tion, the condition is uninfluenced by the usual treatment. There is
no tendency for it to descend and involve the mucous membrane
of the bronchi. The hoarseness of congenital syphiUs is chronic and
of gradual development. Furthermore, if the rhinitis is due to syph-
ihs, other signs are present, or will soon appear, which will make the
diagnosis possible. Measles almost invariably begins as an acute
rhinitis. The accompanying conjunctivitis, the hard, dry, hacking
cough, and the characteristic rash soon make the diagnosis possible.
In nasal diphtheria there is invariably a discharge from the nose
which may be differentiated from simple rhinitis by the fact
that the discharge in diphtheria is excoriating in character and is
often tinged with blood. A diphtheritic discharge may be limited
entirely to one nostril or may be greater from one nostril than the
other; while in acute simple rhinitis the amount of the discharge is
usuallv the same from both sides. The tendency in acute simple
rhinitis in a strong child is toward recovery in five or six days.
When the surroundings are unfavorable, or in dehcate, rachitic
children, active treatment will be required to bring about a prompt
recovery.
Treatment. — In the first stage, that of engorgement, much may
be accomplished in the very young by local measures — menthol, one
grain, dissolved in one ounce of liquid albolene. Of this solution
three drops are instilled into each nostril every hour by means of a
medicine-dropper. This treatment alone will relieve the patient of
a distressing obstruction, thus opening the way to freer breathing.
In older children a spray containing one grain of menthol to an
ounce of liquid albolene may be used at intervals of two or three
hours.
In case menthol and albolene are not at hand, melted white
vaselin may be used in the same way.
For internal use the following medication has served me well:
ACUTE RHINITIS 23I
For a child three months of age :
I^. Tincturae belladonnae gtt. vij
Pulveris camphorae gr- iv
Sacchari lactis, q. s.
M. div. et ft. tablets No. xxx.
Sig. — One tablet every two hours.
Six months of age:
I^. Tincturse belladonnae gtt. x
Pulveris camphorae gr. v
Pulveris Doveri gr. iv
Sacchari lactis, q. s.
M. div. et ft. tablets No. xxx.
Sig. — One every two hours in water.
From one to two years of age :
I^. Tincturae belladonnae gtt. xv
Pulveris camphorae gr- vj
Pulveris Doveri gr. x
M. div. et ft. tablets No. xxx.
Sig. — One every two hours.
At least six doses should be given in the twenty-four hours.
From two to four years of age:
I^. Tincturae belladonnae gtt. xv
Pulveris camphorae Sf- vj
Pulveris Doveri gr. xv
Sacchari lactis, q. s.
M. div. et ft. tablets No. xxx.
Sig. — One every two hours.
If for any reason the tablets cannot be prepared, powders will
answer the purpose equally well.
The above prescriptions are indicated for the second or catarrhal
stage, a condition in which we usually find the patient when brought
for treatment. In their use we must guard against the constipa-
ting effects of the camphor and the Dover's powder.
I would warn here against the forcible use of the syringe in
the treatment of nasal disorders, or any form of nasal irrigation
with any of the saline solutions which requires force for its use.
Infection is easily carried into the eustachian tubes which may be
the starting-point of very grave complications, a suppurative otitis
being thus very easily produced.
Mothers should be instructed to use an enema of warm sweet-
oil or soapsuds if the bowels do not move once in twenty-four hours.
In children of a markedly constipated habit the Dover's powder
may be omitted. Internal medication, if begun early and properly
carried out, will not be needed for more than two or three days.
During an attack of acute rhinitis, the child should not be unneces-
sarily exposed to cold, as there is a strong tendency for the disease
to descend and involve other portions of the respiratory tract.
232 DISEASES OF THE RESPIRATORY TRACT
CHRONIC RHINITIS ? NASAL CATARRH
A nasal discharge, more or less constant, is present in not a few
children during their entire child life. In the majority this dis-
charge begins with the onset of cold weather and lasts until spring.
It may be composed of thin, watery mucus, or it may be muco-
purulent in character.
It may be due to several causes, which will be given in the order
of their frequency; for, in order to treat this condition successfully
the source of the discharge must be discovered :
1. Adenoids in the nasopharyngeal vault.
2. Hypertrophy of the turbinated bones, with septal deviations,
and hypertrophy of the mucous membranes.
3. Infection due to pyogenic bacteria. When present it may
follow an acute rhinitis, but it is more often the sequel of one of
the infectious diseases. The discharge may be distinctly purulent
and is often very profuse.
4. Infection due to the Klebs-Loeffler bacillus. I have seen
ten cases in children from four to eight years of age in which there
was a serous discharge from one or both nostrils, which had per-
sisted for a considerable period of time, in one for an entire year.
Examination of the discharge showed it to contain the Klebs-Loeflfler
bacillus. These children were not ill, and were brought to us for
the discharge alone. Such cases do not clear up under the ordinary
methods of treatment, but promptly respond when from 1500 to
2000 units of diphtheria antitoxin are given.
5. With hay-fever there is a periodic discharge which may be
said to be chronic in character, extending over several weeks.
6. Malnutrition. A thin, watery discharge apparently due to
relaxed mucous membranes is seen in weak and poorly nourished
children, with no other symptom to explain the trouble except
the general weakness.
7. Foreign bodies. A foreign body in either nostril will produce
a persistent discharge. When a child is brought to me with a
history of a persistent serous or purulent discharge from one nostril,
I invariably examine for a foreign body, and repeatedly I have
found this discharge explained by the presence of a pea, a bean,
a piece of coal, or a button. A few weeks ago at the out-patient
department of the Babies' Hospital, a child three years of age was
brought in because of a persistent right-sided nasal discharge
which had existed for seven months. Examination showed that
there was a foreign body well up in the nostril. This was removed
with considerable difficulty and proved to be a piece of cork.
In these cases of chronic rhinitis the possibility of adenoids
(see page 426) should never be forgotten; for they cannot be
excluded because a child is not a mouth-breather and does not
RECURRENT CORYZA AND ANGINA 233
snore. Given a child with a chronic, so-called "cold in the head,"
and you will almost invariably find a child with adenoid vegetations
in the nasopharyngeal vault. Examination may reveal the naso-
pharyngeal space blocked by the growth, so that the entrance with
the finger is almost impossible, or there may be but a small pulpy
mass, or a ridge or soft, friable growth at the upper portion of the
vault, not large enough to produce signs of obstruction, but, actively
secreting, it proves to be the source of the discharge. Children
who have anterior nasal defects, such as hypertrophies of bone or
thickening of the membranes, will usually have adenoids as well.
In fact, adenoids play no small part in most of the catarrhal affec-
tions of the upper respiratory tract in children, and an examination
of a child with a nasal discharge or a cough which is difficult to
account for, is never complete without an exploration of the naso-
pharyngeal vault.
Treatment. — The treatment consists in correcting the condition
which causes the discharge. If adenoids are present in a sufficient
amount to cause trouble, they should be removed (page 427). No
other treatment is of any avail. For deformities and hypertrophies
of the anterior nasal structure, operative measures are also essential,
but should be carried out by one skilled in rhinoplastic work. Puru-
lent rhinitis, primary or following the infectious diseases, is best
treated by a spray composed of liquid albolene, one ounce, ichthyol
ammonia sulphate, two grains, which should be thoroughly shaken
before using. This should be used as a spray every two hours
while the child is awake. Once or twice a day it may be well, if
the secretion is profuse and purulent, to instil into the nostril about
20 minims of a one-to-six aqueous solution of hydrogen peroxid.
If the Klebs-Loeffler bacillus is present, antitoxin alone will control
the disease, and that very promptly.
The anemic and malnutrition cases, which show almost no ab-
normality, but suffer more or less from a constant serous discharge,
are benefited by constitutional measures only — a drv climate, plain,
nourishing food, iron, cod-liver oil, massage, and salt baths. Their
management is referred to in detail under The Management of
Delicate Children (page 142). In these children, local treatment
other than that of cleanliness is a loss of time and energy. The
operation for the removal of adenoids, the treatment of hay-fever,
and the methods of removing foreign bodies from the nostrils are
all referred to under their respective headings.
RECURRENT CORYZA AND ANGINA
Occasionally we see patients in whom there is a history of fre-
quent so-called "colds" with fever, profuse nasal discharge, and
sore throat. Several attacks occur each winter and usually two
or three during the summer months. Adenoids probably were
234 DISEASES OF THE RESPIRATORY TRACT
present originally and possibly enlarged tonsils; but after their
removal the attacks persisted, though perhaps they were less fre-
quent and less prolonged. Still the tendency to coryza was by
no means obviated and the parents are vigorous in their denuncia-
tion of the operator and adenoid operations in general.
These cases are of the same type as those of recurrent bronchi-
tis, and the suggestions under that head (page 261) will be the best
for us to follow here.
NASAL HEMORRHAGE
Nasal hemorrhage in a child is usually due to one of two sources —
adenoid vegetations in the nasopharyngeal vault or an erosion or
ulceration of the mucous membrane covering the free vascular
area of the anterior portion of the nasal septum.
Treatment. — When the hemorrhage is due to an adenoid growth,
it is usually readily controlled by keeping the child in an upright
position, or by the application of cold to the back of the neck — pref-
erably by a piece of ice wrapped in a table napkin or by an ice-bag.
When the hemorrhage is due to an erosion of the septum, pressure of
the finger on the outer side of the bleeding nostril will effectually
control it, or the nostril may be packed with cotton saturated with a
5 percent solution of antipyrin or a i : 2000 solution of adrenalin.
For permanent relief, and to prevent a recurrence of the hem-
orrhage, adenoids should be removed and an excoriated or ulcerated
septum cauterized with a 50 percent solution of silver nitrate.
If the ulcer is first cleaned with plain water, ordinarily but one or
two applications of the silver solution will be required. Spraying
the affected side with a i percent solution of ichthyol in liquid
albolene will hasten the healing process. As the ichthyol is not
soluble in the oil, the mixture should be well shaken before using.
THROAT EXAMINATION
In order to examine the throat of a young child quickly and
thoroughly, it is necessary that he be held in a proper position
in front of and at the right side of the attendant, supported by her
left arm, beneath the buttocks. Her right arm, which is thus left
free, is passed around the child, binding his arms to his sides (Fig.
22). The child's head rests against the shoulder of the attendant.
The physician places his left hand on the child's head to steady
it, and with the tongue depressor or teaspoon in his right hand, with
the child in perfect control, the tongue is pressed downward so
that it will not obscure the field of vision. With an older and
stronger child, it is best to bind the arms to its sides with a large
towel or small sheet. The most satisfactory view can be obtained
by daylight before a window. If the examination is made in the
evening, a lamp or taper held by a third person, a little above and
FAUCITIS 235
behind the attendant's right shoulder, will furnish a satisfactory
illumination. The head-mirror should be used for children who
are too ill to be taken out of bed, the reflection from a lighted lamp
or candle being sufficient.
FAUCITIS
By the term "faucitis " we understand an inflammation of
that portion of the mucous membrane of the buccal cavity situated
ITION OF THE ThROAT.
posteriorly to the soft palate and the anterior pillars of the fauces,
including both the anterior and posterior pillars, the tonsils, and
the pharyngeal wall. The inflammatory process is superficial, in-
volving the mucous membrane only, so that the tonsils are involved
only to the extent of the mucous membrane.
Faucitis is always present in scarlet fever, usually to a marked
236 DISEASES OF THE RESPIRATORY TRACT
degree. In measles it is also present, but it is less intense in its
manifestations. Its most frequent appearance is in connection
with a summer cold. Every year in late May and June I am called
upon to treat a great many such cases. There is always cough,
dry and ineffective, with a sHght fever, from 100° to 101° F. The
child complains of sore throat and there is some discomfort in swal-
lowing. Upon inspection, an intense inflammation will be noticed
involving the entire visible mucous membrane. In many cases
the inflammation extends downward and involves the larynx, which
will be indicated by the hoarse, croupy character of the cough.
The entire illness is ordinarily of three or four days' duration.
Treatment. — The condition is best relieved by a purgative of
rhubarb and soda — 3 grains of powdered rhubarb and 3 grains of soda
for a child from two to five years of age. For a child under two
years of age i to 3 grains of rhubarb and i to 2 grains of bicar-
bonate of soda may be given. This in a child from one to three
years of age is followed by a tablet or powder of tartar emetic t^V
grain, powdered ipecac ^V grain, and chlorate of potash i grain, at two-
hour intervals. Older children, three years and over, receive 2 to 3
grains of chlorate of potash, 9V grain of tartar emetic, and 4V grain
of ipecac at two-hour intervals — six doses in twenty-four hours.
PHARYNGITIS
Inflammation limited to the posterior pharyngeal wall is of
rather infrequent occurrence in young children. When present,
the parts present a reddened, granular appearance. In the cases
which have come under my observation, such a condition has always
been associated with digestive disturbances. The tongue is usually
coated and the breath foul. A dry cough and frequent attempts
at clearing the throat are the usual symptoms. The temperature
is rarely above 101° F. It is to be distinguished from the pharyn-
gitis which occurs as a result of exposure, in that only the posterior
wall is involved, the adjacent structures remaining unchanged.
Thus the tonsils and pillars of the fauces and the soft palate present
a normal appearance.
The treatment is to reduce the diet for a few days to cereal
gruels, — barley, rice, or wheat, — or to chicken or mutton broth.
Calomel, yV grain with one grain of rhubarb after feedings, three
times a day for three days, will promptly relieve the condition.
TONSILLITIS
The onset of tonsillitis is usually sudden. There may be a chill,
and in a few of my cases an attack has been ushered in by convul-
sions. However, the usual mode of onset is with fever, 101° to
103° F., lassitude, loss of appetite, and muscular soreness. Young
children may show difficulty in swallowing and older children may
TONSILLITIS
237
complain of pain in the throat. Not every case of tonsilUtis,
however, is associated with pain in the throat. Inspection re-
veals the tonsils swollen and reddened, covered perhaps with light
colored, cheesy deposits scattered over the surface. In some in-
stances the disease limits itself to swelhng and redness; in others
the cheesy deposit is an early symptom. The exudative areas
may remain distinct and single or they may coalesce, forming a
pseudo-membrane. The duration of the disease ordinarily is from
three to five days. During the attack the patient feels ill, and often
the prostration is considerable. There may be a slight swelling
of the lymphatic glands at the angle of the jaw, but this is usually
absent. If there is a great deal of tenderness of the glands with
a sore throat, it is a suspicious sign, and should make one examine
very carefully for diphtheria.
Differential Diagnosis.— Tonsillitis must be differentiated from
tonsillar diphtheria, and there are few harder problems to solve; in
fact, in many cases, early in the attack, the solution is impossible
without a bacterial examination. The following characteristics of
the average case of the two diseases may aid us in differentiating.
Tonsillitis. — Onset sudden; fever high at onset, 102° to 105° F.
Glands at the angle of the jaw slightly swollen, if at all. Exudation,
follicular, appears as small dots; membrane may form through
coalescence.
Tonsillar Diphtheria. — Onset gradual; fever usually low at
onset, 100° to 102° V. Lymphatic glands at the angle of the jaw
considerably swollen; membrane present on the tonsil, appears
in thin grayish layers which gradually become thicker and more
extensive.
Mixed Injection. — A case of mixed infection may present at
first a picture of a typical tonsilHtis. The temperature may vary
from 103° to 105° F. There is pain upon swallowing, prostration,
and loss of appetite with a follicular exudation. The case remains
stationary for from twenty-four to forty-eight hours, when
the dots coalesce, forming a firm membranous deposit, the lymph-
nodes at the angle of the jaw enlarge, and, in short, both the clinical
manifestations and the bacterial examination show that we have
to deal with a case of diphtheria.
The cases of diphtheria which are preceded by a clinical ton-
sillitis are probably the most dangerous. Such a case was primarilv
a tonsillitis and diagnosed as such, and for several days considered
to be only a tonsillitis, in spite of the membranous deposit w^hich
formed later. This gives abundant opportunity for the exposure
of other children, and the delay in making the diagnosis postpones
the use of antitoxin, rendering the remedy of little or no avail when
finally given. It is my rule to consider as diphtheria every case
in which there is a pseudo-membrane on the tonsils, and to treat it
238 dise;ases of the respiratory tract
with antitoxin without waiting for a bacterial examination. Further-
more, when there are other children in the family, I invariably quar-
antine every case of simple tonsillitis.
Treatment. — Local treatment of the diseased parts in tonsillitis
by spraying, swabbing, and painting has been of very little service in
my hands, particularly in children under four years of age. When
the child is held by force for such treatment, thoroughness is im-
possible and little or nothing is accomplished. For tractable children
and those old enough to understand what is being done, gargles,
sprays, and irrigations arc useful in so far as they relieve pain and
cleanse the diseased parts. A useful gargle is the following:
I^. Sodii salicylatis
Sodii biboratis
Sodii bicarbonatis aa gr. xlv
Essentia menthse piperita; oj
Aquae q. s. ad 5ij
Sig. — One teaspoonful in one-half glass of water at 115° F. Gargle
entire quantity every hour.
A useful spray is the following:
I^. Acidi borici gr. Ix
Aquae menthae piperitae oviij
M. Sig. — Spray throat every two hours.
Irrigation of the throat is indicated in tonsillitis not only on
account of cleanliness, but because of the relief from pain which
it affords. In severe tonsillitis, with much swelHng and the con-
sequent tension, the pain upon swallowing is often excruciating.
For the irrigation there are needed a fountain syringe and a
clean tube for introduction into the mouth. The child may lie
down or sit up, as preferred. If in the recumbent position, the
head should be turned to one side, the mouth resting over a
pus basin, which catches the water as it passes out during the
irrigation. If it is preferred to give the irrigation with the patient
sitting erect, a basin held under the chin will catch the water as it
flows from the mouth. Two pints of a normal salt solution — one
teaspoonful of salt to a pint of water — at 115° F. is placed in the
bag, which has previously been warmed. The bag is held two
feet above the child's head and the solution is allowed to flow
in a brisk stream against the swollen parts, until at least one pint
of the solution has been used. The irrigations if they furnish much
reUef may be repeated in from four to six hours.
It is advisable to begin the treatment with a laxative. One
grain of calomel in divided doses, one-sixth grain every hour, answers
well. The child's food is reduced. If bottle-fed, the milk is given
one-half strength, one-half quantity of the milk mixture being
given with an equal quantity of water. The fever, if high, is readily
controlled by cool sponging (page 480).
HYPERTROPHIED TONSILS 239
The only drug which has appeared to me to possess any signal
value for internal use in tonsillitis is chlorate of potash. One grain
at two-hour intervals for a child one year of age; 2 grains at two-
hour intervals for a child two years of age — 16 grains in twenty-
four hours; 3 grains for a child three years of age — 24 grains in
twenty-four hours. I rarely give more than 3 grains at two-hour
intervals at any age. I have used chlorate of potash in this way
for several years, and I have never been able to associate the drug
with kidney complications in one of the hundreds of cases in which
I have used it. It is usually made in solution with simple elixir
and water, or syrup of raspberry and water.
Cold compresses to the throat are of aid in older children — those
who can appreciate the necessity of the treatment. In the young,
those under two years of age, it is impossible to keep the applica-
tions in position. My instructions are to fold and soak a table
napkin in cold water, 40° to 50° F, The compress should be about
2^ inches wide and from four to five thicknesses of the material
should be used. The water is pressed out and the dressing is placed
under the jaw so that the ends reach to the ears. The compress
is held in position by a handkerchief or a piece of cheese-cloth,
which passes over and around it, and may be tied at the top of the
head. It should be removed every thirty minutes, wrung out of
cold water, and reapplied. When the compress is put on as we
often see it, wrapped around the neck, it will be of no service, as
it does not even touch the parts affected. Children who have
repeated attacks of tonsillitis are put on anti-rheumatic treatment
(page 464) in the intervals between attacks.
HYPERTROPHIED TONSILS
Chronic enlargement of the tonsils is usually the result of several
acute attacks of tonsillitis. A tonsil is said to be enlarged when
it extends beyond the pillars of the fauces. Enlarged tonsils pro-
duce mouth-breathing, disturbances of speech, and eustachian-
tube catarrh, and they are doubtless a factor in adenoid etiology.
Children with enlarged tonsils are also particularly susceptible to
diphtheria. In the crypts are harbored myriads of bacteria, which,
under favorable conditions, produce repeated attacks of acute
inflammation: the pneumococcus, the tubercle bacillus, the Klebs-
Loeffler bacillus, and many other pathogenic bacteria have repeat-
edly been found in the tonsillar crypts. Children of rheumatic
inheritance are very apt to have enlarged tonsils.
Treatment. — The treatment consists in removal — excision (see
page 426). Sprays, gargles, and local applications are of little or no
avail. When, for any reason, the operation is not possible, cauteriz-
ing with a galvanic cautery is indicated. Several sittings at intervals
of five or six days will be required, however, to reduce a tonsil of
240 DISEASES OF THE RESPIRATORY TRACT
any considerable size. Occasionally cases are seen in which the
tonsils are broad and flat, with marked increase of connective
tissue and dilated crypts; in such cases when the tonsil is not large
enough to be removed with a tonsillotome the tonsil punch or
the cautery may be brought into use. A few sittings will prac-
tically remove the tonsil, and its possibilities as a culture-field for
pathogenic bacteria is destroyed. The application of a 5 percent
solution of cocain on a swab will render the cauterization com-
paratively painless.
Hypertrophied tonsils should be removed for two reasons: (i)
their obstruction to respiration, and (2) their capacity for har-
boring all sorts of bacteria, among which the tubercle bacillus and
the Klebs-Loeffler bacillus are the most important.
PERITONSILLAR ABSCESS; QUINSY
The seat of a peritonsillar abscess is in the cellular tissue about
the tonsil. It may be above, in front of, or behind the tonsil. The
disease is seen rather infrequently in children. I have seen but
one case in a child under six years of age. It usually follows a
tonsillitis. In none of my cases has it followed diphtheria, scarlet
fever, or measles. The history is usually as follows:
The child has a tonsilHtis with the usual symptoms, with the
addition of greatly increased swelling and pain upon swallowing.
He complains of pain in the muscles of the neck on the affected
side, the head being held toward that side. A fairly early symp-
tom is inability to open the mouth to the usual extent. In the
average case, inspection reveals a reddened, edematous swelling
slightly above and in front of the tonsil, causing a forward displace-
ment of the uvula. In a few instances I have seen it develop behind
the tonsil, in which case the tonsil on the affected side will appear
unduly prominent. This type of case is very apt to be overlooked
unless a digital examination is carefully made, when a soft, fluc-
tuating swelling will readily be felt behind the tonsil.
Treatment. — The treatment is by incision. This, however, should
not be made until the abscess is fully developed. If the incision is
made too early, it has in my cases invariably closed and required re-
opening. This closure sometimes occurs even after a timely opera-
tion, because too small an incision is made and the contraction of the
abscess wall necessarily following the free discharge of pus and blood
effectually closes the opening.
For operation the patient should be wrapped in a large towel
or sheet to bind the arms securely to the sides. He should sit in
an upright position on the lap of the attendant, against whose
right shoulder his head rests. The left arm of the attendant is
passed around the patient, holding him firmly, while the right hand
grasps his forehead. A Denhard gag of the 0'Dw3^er set should
PERITONSILLAR ABSCESS; QUINSY 24 1
be used to hold the mouth open. Either by the use of reflected
Ught from a head-mirror, or with the patient facing a window,
the operator, using a guarded bistoury, makes a free incision in
the abscess from above downward. The escape of a considerable
amount of blood usually follows the withdrawal of the knife. Often-
times more blood than pus is discharged. This is particularly
apt to be the case if the abscess is opened early.
It is interesting to note that the cases which open spontane-
ously never heal spontaneously. In addition to a free incision
it is my custom, during my daily visits immediately after the opera-
tion, to prevent a closure of the wound by passing into it a director,
and, by moving it up and down, break up any beginning granula-
tions. With free, uninterrupted drainage the case is usually well
in from three to live days.
Aside from a saline laxative, which should be given early in
the attack, internal medication is valueless. Two drams of Rochelle
salts or six ounces of a solution of citrate of magnesia are usually
ordered. Other means of treatment are directed to the comfort
of the patient. An ice-bag applied externally before operation
may be grateful to the patient. Our greatest means of furnishing
relief, however, lies in the use of the hot saline irrigation, and the
hot gargle where practicable. But few children can gargle well
enough to make this advantageous, so that ordinarily it is best
dispensed with. With the few cases where it is practicable, I
have found the following prescription and method of use of service:
I^. Sodii bicarbonatis gr. xlv
Essentise menthae piperita? 5j
Aquae q. s. ad 5 ij
Sig. — Add 1 teaspoonful to 6 ounces of water at 120° F. and gargle entire
quantity every half hour.
The pain occasioned by gargling is another objection to its use
in children. A far more effectual means of relieving pain in this
disease, and one which causes no effort and distress whatever, and
which gives astonishing relief, is a saline irrigation which is prepared
and given as follows: A heaping teaspoonful of salt is added to one
pint of water at 120° F. This is placed in a fountain syringe which
is previously warmed. A towel is placed around the patient's
neck, to protect the clothing. The basin is held under the mouth,
to catch the drainage. With everything in readiness, the bag con-
taining this solution being hung from two to three feet higher than
the child's head, the end of the rubber tube, a part of every foun-
tain syringe, without the hard-rubber tip attachment, is placed
in the child's mouth and the hot solution is allowed to flow against
the inflamed surfaces until the entire pint has been used, pressure
being maintained upon the tube so that the flow will not be too
free. For the first irrigation or two, there will be more or less cough-
16
242 DISEASES OF THE RESPIRATORY TRACT
ing, and the child may have to rest after an interval of a few minutes.
After he becomes accustomed to the procedure the entire pint
may be used without intermission. The irrigations may be repeated
every hour and may be used as well after as before operation. When
once the child experiences the relief afforded, there will be no trouble
in repeating the irrigation.
RETROPHARYNGEAL ABSCESS; SUPPURATIVE RETRO-
PHARYNGEAL ADENITIS
A retropharyngeal abscess is usually a streptococcus infection
of one or more of the retropharyngeal lymph-nodes which form a
chain on either side of the median line, posterior to the pharynx
and between the pharyngeal and the prevertebral muscles. The
nodes are said to disappear at about the third year of Ufe. It has
never been my privilege to see a case in a child over three years
of age. The disease is very liable to be overlooked. Seven of
my cases had been treated — and all but one of them treated by
more than one physician — for something other than retropharyngeal
abscess. This failure to recognize the affection has been com-
mented upon by others, recently by Morse, of Boston. It is due
to two causes: First, pediatric writers in their description of the
disease have laid down too narrow and definite a symptomatology;
second, the lack of thoroughness on the part of physicians in the
examination of their cases results in their failure to discover the
true nature of the case.
In describing the disease, writers tell us that the patient holds
his head in a characteristic position, backward and toward the
affected side ; that the breathing is noisy and stertorous in character ;
that there is difficulty in swallowing ; that there are enlarged lymph-
glands at the angle of the jaw, and that, on examination, a bulg-
ing of one side of the posterior pharyngeal wall is usually dis-
covered. Only four of my ca-ies showed the above combination of
symptoms. All the cases showed but two symptoms in common —
difficulty in swallowing and changed voice. Other than this the
cases varied widely, depending upon the location of the abscess.
Obviously, an abscess situated low down on the posterior pharyn-
geal wall will not manifest itself in the same way as one high up
behind the soft palate.
Illustrative Cases. — A baby nine months of age had been under
treatment in one of the outdoor clinics of New York city. A diag-
nosis of adenoids had been made and a day appointed for the opera-
tion. The mother, wishing to have the diagnosis of adenoids
confirmed, brought the child to the out-patient department of the
Babies' Hospital. The symptoms of mouth-breathing, nasal voice,
and sUght difhculty in swallowing had been present for a couple of
weeks. There was no characteristic position of the head, no rigid-
RETROPHARYNGEAL ABSCESS 243
ity of the neck, no superficial enlargement of the lymphatic glands.
Inspection of the throat disclosed a bulging forward of the soft
palate on the right side. A digital examination revealed a round,
fluctuating mass, the size of a hickory-nut. It was found high on
the posterior pharyngeal wall and almost entirely covered by the
soft palate. No adenoids were present.
A baby two years of age had been ill for a week with tonsillar
diphtheria and was thought to be recovering, when suddenly the
voice became hoarse and croupy, with gradually increasing dyspnea.
There was both expiratory and inspiratory obstruction, such as
we expect in laryngeal diphtheria, and the attending physician,
an excellent practitioner, naturally concluded that the diphtheritic
process had extended to the larynx. There was stiffness of the neck
but no nasal obstruction. The voice was hoarse and croupy in
character. There was slight difiQculty in swallowing. Inspection
of the throat with a dim light revealed nothing but the enlarged
tonsils. I was called to intubate, and finding the respiratory ob-
struction sufhcient to require intubation, I proceeded to make a
digital examination, as is my custom before intubating. I was
not a Httle surprised to find a soft, fluctuating mass low down in
the pharyngeal wall, extending below and pressing against the
glottis. The abscess was opened, with immediate relief to the
obstruction.
A baby, seven and a half months of age, was an inmate of the
country branch of the New York Infant Asylum during my service
in that institution.^ My attention was first called to the child
because of its difficulty in swallowing. There was very little ob-
struction, but the voice was harsh, hoarse, and croupy. About
a month previous, there had been a suppurating submaxillary aden-
itis. On examining the throat, a large abscess was seen on the right
pharyngeal wall, extending downward as far as could be seen. This
case was my first experience with retropharyngeal abscess, and
a Denhard gag of the O'Dwyer set, which should never be used in
these cases, was introduced and the child held in an upright position
by the assistant. While feeling for the thinnest point of the sac
for a suitable place for the incision the child suddenly stopped
breathing, became Hmp and apparently lifeless. An intubation
tube, the smallest of the O'Dwyer set, was quickly introduced with-
out the gag. After several minutes of artificial respiration, the
use of oxygen, and free hypodermic stimulation with brandy, respira-
tion was again established. The first inspiration was so long
delayed that we had almost given up the case as hopeless, when
the first short gasp occurred. In half an hour the child had suffi-
ciently recovered to allow the opening of the abscess. This was
^The case was reported at the time by Dr. Henry E. Tuley, assistant resi-
dent physician.
244 DISEASES OF THE RESPIRATORY TRACT
done without a gag, with the tube in position. After a copious
discharge of pus, the tube was removed and the child recovered.
In this case, the suffocation was due, doubtless, to the introduction
of the gag and the pressure of the finger, which forced the pus into
the lower portion of the sac, which extended below the glottis,
where it exerted sufficient pressure to prevent the entrance of air.
A private patient one year old had diphtheria — laryngeal, fau-
cial, and tonsillar. Under 9000 units of antitoxin and intubation,
satisfactory progress was made, and on the eighth day of the illness
the tube was removed. It had to be replaced in a few minutes
because of returning dyspnea. Upon replacing the tube an abscess
was found in the right posterior pharyngeal wall, pressing upon and
extending below the larynx. The presence of the tube had prevented
the recognition of the abscess, as the voice and breathing were per-
fectly normal. It being decided that this was the cause of the
obstruction, the abscess was evacuated, but the marked edema
of the glottis still caused considerable respiratory obstruction,
and the tube was required for two weeks longer. The child made
a perfect recovery and is well and strong today.
The above cases are cited in detail in order that the reader may
the more fully reahze that retropharyngeal abscess may exist with-
out the so-called "characteristic symptoms," and also to emphasize
the fact that many cases have been, and will continue to be, over-
looked until physicians use the finger as an aid to diagnosis in the
diseases of the upper respiratory tract. It is to be remembered that
there is no "characteristic breathing" and no "characteristic posi-
tion " of the head in retropharyngeal abscess. The disease is usually
secondary to retropharyngeal adenitis, due to infection from ad-
jacent diseased structures. There is always fever, 101° to 104°
F., with loss of appetite. Occasionally the abscess points outward
and requires external incision.
Treatment. — The diagnosis made, there is but one means of treat-
ment— incision and evacuation of the pus. In order to do this it is
necessary that the child be under perfect control. The arms should
be bound to its sides with a large towel or a small sheet securely
pinned. The child is held in an upright position on the lap of the
attendant, who passes his left arm around the child, while his right
hand grasps the forehead, drawing the head for further support back-
ward against the right shoulder. The operation should be performed
in a good light — either reflected light from a head-mirror or direct
light from a window. With a tongue depressor in the operator's left
hand the mouth is kept open, and with the tongue out of the way,
the right hand is free to make the incision, for which an ordinary
scalpel is used. The incision should be from above downward and at
least one-half inch in length. A basin should be in readiness and the
attendant instructed to invert the child at a word from the operator
IRRIGATION OF THE; THROAT 245
as soon as the incision is made. This allows the pus and blood,
which, if aspirated into the trachea, may produce fatal results, to
stream out of the mouth. While the abscess is discharging and the
head dependent, the clean index-finger of the operator should ex-
plore the cavity, enlarge the opening, if necessary, and remove
any necrotic tissue that may be present. The case should be care-
fully watched for several days, as the opening is liable to close
before resolution is complete, particularly if it has not been enlarged
with the finger. Recovery is usually complete in from five to seven
days.
RETROPHARYNGEAL ABSCESS (TUBERCULOUS); CARIES OF THE
CERVICAL VERTEBRA
The condition is usually described as associated with idiopathic
retropharyngeal abscess, though it should not be, as the condition
is a part of and results from tuberculous disease of the spine, which
will be referred to under the proper headings.
IRRIGATION OF THE THROAT
Indications. — In peritonsillar abscess or retropharyngeal abscess
after operation, in sloughing ulcerative processes in the throat, such
as we see in diphtheria rarely, but with comparative frequency in
scarlet fever, irrigation of the throat with hot normal salt solution
is of distinct therapeutic value. The relief to the pain, particularly
in quinsy, before operation, is sufficient to warrant its use. Those
who have treated thus the fetid sloughing throat of scarlet fever, for
example, need no argument as to its possible advantages. Acute
suppurative otitis is always due to the throat infection. Gargling
in children is a measure of very limited usefulness even in those
who do it well, for the reason that the solution employed scarcely
comes in contact with the post-pharyngeal wall and the lateral
faucial structures. In a great majority of older children, and in
all young children, it is practically useless so far as the cleansing
of the deeper faucial structures is concerned.
Cervical adenitis, acute, persistent, and suppurative, is the
direct result of throat infection. An important means of preventing
it, with its distressing consequences, is an effective throat toilet.
Often in scarlet fever not a small part of the systemic infection
after the third or fourth day is through the throat. The irrigation
should be done two or three times a day as follows :
Operation. — The child is wrapped in a sheet, which is securely
pinned, binding his arms to his sides. He rests on his right side with-
out a pillow. Directly under his mouth is a pus basin to catch the
outflow. A new fountain syringe, containing a hot salt solution, 120°
F., is suspended about three feet above the child's body. The
largest size of the hard-rubber rectal tip is fastened to the pipe and
the tip placed between the child's teeth. The current, interrupted
246 DISEASES OF THE RESPIRATORY TRACT
every few seconds, should be forcible enough to increase its efficacy
as a cleansing agent, the volume of fluid being so small that no
inspiration of the water occurs.
The first irrigations will arouse more or less rebellion on
the part of the patient and but one-half pint of the solution
need be used. In older children no trouble will be experienced after
the relief afforded by the first injection is appreciated. In refrac-
tory young children, from two to four years of age, the assurance
that there will be no pain and a promised reward will reduce the
struggling to a minimum. It is not to be expected that the child
will not cough; in fact, a moderate amount of coughing is desirable,
as it dislodges the pus and sloughing tissue, enabling the solution
to cleanse the parts more effectually.
ACUTE CATARRHAL LARYNGITIS ; SPASMODIC CROUP
By acute catarrhal laryngitis we understand an idiopathic ca-
tarrhal inflammation, involving the larynx and the adjacent structures.
Nervous, rachitic children are particularly susceptible to the disease.
Adenoids are often a predisposing cause. The onset may be sudden
or gradual. Cases which are of a gradual onset usually follow an
acute inflammatorv condition of the nasopharynx. At first there
is usuallv a catarrhal rhinitis, the fauces and larynx becoming suc-
cessively involved, requiring two or three days, perhaps, before
the laryngitis is well marked. The temperature is usually not high
at the onset. One of the early symptoms indicating laryngeal
involvement is a hard, dry cough, croupy and "barking " in char-
acter. The croupy element in the cough increases in severity to-
ward evening.
In the cases with sudden onset, the child retires at the usual
hour in apparently good health; a few hours later he wakes with
a characteristic cough. Whether the case is of sudden or gradual
onset, the care is practically the same after the cough develops.
Many cases stop at this point. There is a severe cough for a few
days which subsides under proper treatment. For a few of the
cases, however, the course is not so favorable ; the cough continues,
becoming stridulous, every inspiration being accompanied by a
loud crowing sound. Occasionally a case will be seen with marked
laryngeal obstruction, due to the swelling and laryngeal spasm,
that will require intubation. In my experience, however, this
is very rare, as I have had to intubate but one child with catarrhal,
non-membranous croup — an infant sixteen weeks old.
Acute laryngitis may be confused with diphtheritic or mem-
branous laryngitis. For differentiation, see page 304.
Laryngismus stridulus may be mistaken for catarrhal laryngitis.
It is easy to differentiate, when one remembers that there is no
cough in uncomplicated laryngismus stridulus, and that the laryn-
ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP 247
gcal spasm is usually associated with excitement, fright, or some
other nervous inlluence. l"\irther, laryngismus stridulus does not
occur as a defmite illness, the laryngeal spasm, mild or severe,
occurring, as a rule, several times a day, covering a period of weeks
or months. The continued obstruction, always associated with in-
flammatory conditions of acute catarrhal laryngitis, is absent.
Fig. 23.— Crih Preparkd for Steam Lnhai.ahon.
Treatment. — In the treatment of catarrhal laryngitis in children,
two factors must be kept in mind: First, the congestive infiltration
and dryness of the parts, which cause the metallic cough and the
stridulous breathing; second, the laryngeal spasm, which is purely
a. nervous manifestation, due, doubtless, to the irritation of the ter-
minal fdaments of the recurrent laryngeal nerves which supply the
larvnx.
248
DISEASES OF THE RESPIRATORY TRACT
Not in every case of laryngitis in children by any means do
we have croup. But when croup is present, we know that back
of it there is laryngeal spasm with congestion and inflammation.
If we are to treat these cases of catarrhal croup successfully, with
quick recoveries, we must not lose sight of the nervous element,
which is considerable.
Expectorants. — For the simple coughs, without interference with
respiration, the expectorant and steam treatment answer admirably,
regardless of the age of the child. This special treatment should be
Fig. 24.— The Holt Croup Kettle.
preceded by a full dose — from one to three teaspoonfuls — of castor oil.
For a child under one year of age a tablet composed of tartar emetic
y^-Q grain with powdered ipecac g^ grain should be given every two
hours — eight doses in the twenty-four hours. If the tablets or
powders are not to be had, two drops of syrup of ipecac may be
given instead. For a child from one to two years of age a tablet
ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP 249
or powder composed of yV,j grain of tartar emetic, 4V grain of pow-
dered ipecac, | grain of Dover's powder at two-hour intervals,
eight doses in twenty-four hours. After the first day the treatment
should be commenced early in the morning, so that by evening,
when the cough and spasm are at their maximum, the full influence
of the drugs may be felt. From the third to the sixth year, a powder
or tablet composed of tartar emetic gV grain, powdered ipecac 3V
grain, and Dover's powder ^ grain should be given at two-hour
intervals, eight doses in twenty-four hours. At least eight doses
of one of the above prescriptions should be given daily, in order to
get the full benefit of the drugs employed. If the Dover's powder
produces constipation it may be omitted, or a laxative may be given;
usually the treatment need not be continued more than two or
three days. In case the attack is mild, it is best to omit the Dover's
powder.
Cold Compresses. — In older children a cold compress to the throat
is a valuable local measure. A napkin or piece of old linen answers
best for this purpose. It is so folded that there are at least six thick-
nesses of the material. This is moistened with cold water at 60° F.,
wrung thoroughly, and placed against the neck, under the jaw, so as to
extend from ear to ear. Over this should be placed a piece of oiled
silk or rubber tissue, and all held in position by a strip of thin muslin
or cheese-cloth, which should be brought together at the ends and
fastened at the top of the head. The compress should be changed
every thirty minutes. In very young children this treatment is rarely
satisfactory, for the reason that it is difficult to force the child
to allow the bandage to remain in place. The practice of placing
the compress around the neck, as is often done, is of no value, as
it does not even touch the diseased parts.
Steam Inhalations. — Steam inhalations are effective onlv when the
patient is kept in an enclosed space. The steaming kettle in the room
is of little or no service. The easiest and most practical place for
the child is in its crib, which should be covered with a sheet. An
open umbrella may be substituted when a crib is not available. Under
the umbrella, which rests upon the bed, lies the child, and covering
all is a sheet which is pinned to the umbrella ; or the umbrella may
be opened and placed over the baby-carriage and draped as before.
Any means or apparatus which will furnish steam and conduct it
to the enclosed space containing the child will answer. The Holt
croup kettle (Fig. 24) is always to be used when obtainable. The
steaming may be continued for hours, if required. The sheet should
be removed occasionally for a few moments, in order to allow a
change of air. Usually a child is kept under the tent from twenty
minutes to one-half hour without such a change. The tent is seldom
so close as to prevent all ventilation.
Calomel Fumigations. — A quicker and more effectual means than
250
DISEASES OF THE RESPIRATORY TRACT
steam is the use of calomel fumigations. The patient is placed under
a tent prepared as above. The Ermold lamp, made especially for this
purpose (Fig. 25), is recommended, but the ordinary alcohol lamp used
for warming milk answers every purpose. Ten grains of calomel are
placed in any tin receptacle, which rests or is held over the flame.
An ordinary kerosene lamp has served me well in a few instances,
the calomel being placed in the cover of a tin can which was held
by a pair of pincers over the top of the lamp chimney. Regardless
of the method, the fumigation must be constantly watched by
some competent person, so as to avoid the possibility of igniting
the bedclothes. When the fumes begin to fill the tent, the child
will cough considerably. If the cough continues for more than a
few minutes, it is advisable to allow a portion of the vapor to escape.
The calomel will be consumed in from
five to ten minutes, depending upon
the degree of heat used. After the
tent is filled with the vapor, allow^ the
child to inhale it for about one-half
hour. The vapor produces a free se-
cretion from the mucous membrane
of the parts and a local depletion,
with enlargement of the lumen of the
larynx and consequent relief of the
symptoms. The fumigation may be
repeated after an interval of two or
three hours. In a non-diphtheritic
case I have rarely had to repeat the
inhalations more than two or three
times.
Anti-spasrnodics. — In the cases of
sudden onset, in which the spasmodic
element is prominent at the commence-
ment of the attack as indicated by the high-pitched crowing inspira-
tion, and in some extreme cases by the struggle for breath, the cyano-
sis, the stridor, and the infrasternal recession, the above treatment
will not answer. In such cases we must combine an expectorant with
anti-spasmodic drugs. A full dose of syrup of ipecac — one to two
teaspoonfuls, or sufficient to produce emesis — should be given at once.
If vomiting does not take place in twenty minutes, the ipecac should
be repeated. After emesis has taken place, the antispasmodic reme-
dies should be brought into use. Antipyrin and sodium bromid are
especially effective at this stage. Antipyrin appears to have a direct
sedative action on the nervous mechanism of the larynx. To a child
two years of age the following prescription is often given :
Fig. 25.— Ermold's Lamp.
LARYNGISMUS STRIDULUS 251
I^. Antipyrini gr. j
Sodii iaromidi gi'- ij
Syrupi ipecacuanha? iijij to iij
Aquae q. s. ad 5j
M. Sig. — Give one such dose every two hours — eight doses in twenty-
four hours.
To a child from three to six years of age may be given :
I^. Antipyrini gf. ij
Sodii bromidi gr. iv
Syrupi ipecacuanhas gtt. iij
Syrupi rhei gtt. xv
Aquae q. s. ad oj
M. Sig. — Give one such dose every two hours^eight doses in twenty-
four hours.
The medication and other treatment are to be discontinued as
soon as the dyspnea ceases.
LARYNGISMUS STRIDULUS
Laryngismus stridukis is a spasm of the larynx occurring most
frequently in infants. It is rarely seen after the first 3^ear. The
spasm may cause a partial or complete closure of the glottis.
The severity of the symptoms depends entirely upon the degree
of the spasm. In the mild cases, sudden inspiratory effort, as in
coughing or crying or from fright, will be sufficient to bring on an
attack. The child gives vent to a long-drawn inspiratory crow
similar to a whoop in pertussis. This may be followed by apnea
which lasts for a few seconds, during which time the child becomes
blue in the face. This is soon succeeded by a series of short gasps,
and normal respiration rapidly returns. In the more severe and
rarer cases, the spasm occurs without warning. This is particularly
apt to be the case in the very young — those under six months of
age. There is a short, quick inspiration and respiration ceases.
The child becomes blue in the face, struggles for breath, and becomes
unconscious. In a few seconds there is a relaxation of the spasm,
accompanied by a loud, inspiratory crow, followed by two or three
others of gradually diminishing intensity until normal respiration
is re-established.
Predisposing Causes. — Laryngismus, according to myobser\^ation,
invariably occurs in weakly children — those suffering from malnutri-
tion and rachitis. Among a large number of cases, the majority of
which were seen in dispensary work, I have never known one in
which there was not some manifestation of rachitis. The presence of
adenoids, or any source of irritation of the upper respiratorv tract,
increases the severity of the spasm and the number of the attacks.
Under properly directed treatment the spasms usually become less
and less severe, and finally disappear, although several weeks of
treatment may be necessary.
Illustrative Case. — A few years ago, a child five months of age came
252 DISEASES OF THE RESPIRATORY TRACT
under my care on account of difficult breathing, rachitis, and laryn-
gismus. The attacks were rather infrequent — once every three or
four days — but they were very severe, and in one of them the child
died. There was no evidence of enlarged thymus gland in this case.
In another child, three months of age, the attacks ranged from
twenty to thirty a day, and were controlled only by a gradual im-
provement in the child's general condition.
Laryngismus may be mistaken for whooping-cough or catarrhal
croup, or it may be associated with both of these affections. When
children with pertussis lose consciousness during a coughing par-
oxysm, the possibility of laryngismus must be kept in mind. There
is always a mild laryngeal spasm associated with severe catarrhal
laryngitis and whooping-cough, and the value of sedatives in these
disorders is explained by their action in preventing laryngeal spasm.
Treatment. — Drugs. — The management is divided into two parts:
the immediate relief of the spasm, and the treatment of the patient's
debilitated physical condition. From my observation, the most satis-
factory method of relieving spasm in the mild cases — those in which
the unconsciousness is of but a few seconds' duration — is by inverting
the patient and at the same time slapping him on the back. Splash-
ing cold water in the child's face may be of advantage in some
cases, but I have found it of but little service. In cases which are
sufficiently prolonged to resist inversion and slapping on the back,
a hasty removal of the outer clothing, with alternate hot and cold
tub-baths, at 60° F. and 120° F. respectively, have been successful,
except in the fatal case referred to, whose death occurred during
my absence. If recovery is not prompt, intubation or tracheotomy
should be performed, followed by attempts at artificial respiration.
Between the attacks, the patient should receive small doses of anti-
pyrin and sodium bromid. Under six months of age, one -half
grain of antipyrin and two grains of sodium bromid may be admin-
istered in one dram of cinnamon-water — six doses being given
in twenty-four hours. From the age of twelve months to the third
year, one to two grains of antipyrin with two to four grains of so-
dium bromid may be administered in one dram of cinnamon-water —
six doses being given in twenty-four hours. The only disadvantage
in the use of these drugs Hes in the fact that these children almost
invariably have faulty digestion, which condition may be aggravated
by the sodium bromid. When this is observed, the bromid is best
omitted and the antipyrin given alone. Antipyrin apparently never
produces any unfavorable effects upon gastric digestion.
Colon medication may be of considerable service in these cases,
and when indicated, bromid and chloral are our most reliable seda-
tives. For a child of six months or under, one grain of chloral
with three grains of sodium bromid may be given in two ounces
of mucilage of acacia; for a child of from six to twelve months.
TRAUMATIC LARYNGITIS 253
two grains of chloral and five grains of sodium bromid in three
ounces of mucilage of acacia; for a child of from twelve to twenty-
four months, two grains of chloral and eight grains of sodium bromid
may be given in two ounces of mucilage of acacia. The bromid
and chloral should not be administered oftener than once in six
hours.
The method of administration is as follows: A large soft-rubber
catheter or a small rectal tube should be attached to a Davidson
syringe and introduced at least nine inches into the rectum so as
to reach the descending colon. The child should rest on its left
side with the buttocks elevated on a pillow so that they are higher
than the shoulders. After the withdrawal of the tube the position
of the child should be maintained for several minutes in order to
aid in the retention of the fluid.
Diet. — The dietetic management of debilitated, rachitic children
suffering from laryngismus is the same as that of other debilitated
children. (See Malnutrition, page 156.) In general, they should
be given as high a proteid diet as is compatible with their digestive
powers. Thus, if there is intolerance of cow's milk given in suit-
able dilution, there should be no hesitation in advising a wet-nurse.
Condensed milk or proprietary foods should not be given such a
child, if better means of nourishment are obtainable. For children
over one year of age, cow's milk, cereals containing a large amount
of nitrogen, soft-boiled eggs, beef-juice, and scraped beef should
form a large part of the diet. Particularly must these children
be kept free from all sources of excitement, such as loud talking,
the over-attention of adults, and the rough, active play of older
children.
TRAUMATIC LARYNGITIS
Traumatic laryngitis, while a very rare condition in children, is
occasionally met with. It may be caused by the inhalation of steam
or irritating gases or the aspiration of carbolic or other strong acids.
I once saw a fatal case due to the aspiration of pure carbolic
acid by a child three years of age who was given a teaspoonful
of the acid by a five-year-old sister. As soon as it passed her lips
the child cried and coughed. None of the acid was swallowed,
apparently, but sufficient was aspirated into the larynx to produce
intense congestion and sufficient edema to require immediate opera-
tive measures. The parts sloughed extensively and the child died
in two weeks from pneumonia, resulting from sepsis.
Treatment. — No case of corrosive injur}' to the mucous membrane,
sufficient to produce congestion and edema with a resulting inspiratory
obstruction which requires operative rehef, should ever be intubated
except as a temporary expedient, since the presence of a tube will
invariably cause extensive sloughing. If the case is urgent, trache-
254 DISEASES OF THE RESPIRATORY TRACT
otomy is the only warrantable operation. In two cases due to irri-
tating gases — sulphur dioxid in one case and steam inhalation in
another^the successful treatment was the use of cold applications
to the neck by means of wet compresses at a temperature of 60° F»
LARYNGEAL OBSTRUCTION
Laryngeal obstruction may be either complete or partial, causing
entire cessation of, or greatly impeded, respiration. As the calls
upon the physician for aid in these cases are attended with great
urgency, it is well to bear in mind the conditions which may give
rise to, or directly cause, laryngeal obstruction. These are referred
to in detail under their respective headings. In order of frequency
they occur as follows:
1. Acute Catarrhal Laryngitis (Catarrhal Croup), page 246.
2. Membranous Laryngitis (Laryngeal Diphtheria), page 304.
3. Retropharyngeal Abscess (Laryngismus Stridulus), page 242.
4. Foreign Bodies in the Larynx, page 254.
5. Traumatic Laryngitis, page 253.
6. New Growths.
Acute catarrhal laryngitis, membranous laryngitis, and retro-
pharyngeal abscess are by far the most frequent causes of laryngeal
obstruction in children. In children, edema is a very infrequent
cause of laryngeal obstruction; it is a complication or a sequel
of other pathologic states; for example, it may result from an
inflammation accompanying a low-placed retropharyngeal abscess^
a traumatic laryngitis after the inhalation of irritating gases, or from
the aspiration of corrosive fluids or powders.
FOREIGN BODIES IN THE LARYNX
Foreign bodies are usually lodged in the larynx by an act of
sudden inspiration attended by a quick forward movement of the
head, as in coughing or laughing with a foreign body in the mouth
or between the teeth. The patient is immediately seized with a
violent paroxysm of coughing and suffocation, the severity of which
depends upon the size and shape of the foreign body.
Inversion of the patient was of no service whatever in the cases
seen by me. The first thing to do is to introduce into the mouth
the index-finger, with the hope that a portion of the mass may
protrude sufficiently to make possible its removal. Should this
fail, a laryngeal forceps should be brought into use, its introduction
being guided and guarded by the index-finger. When this is not
successful, tracheotomy should be performed to relieve the child
from immediate danger of suffocation, after which further surgical
procedures may be considered. Intubation, it is hardly necessary
to state, should not be attempted.
PERSISTENT COUGH 255
PERSISTENT COUGH
I have had occasion to examine and treat many children who
were brought to me because of a "cough" which had not been
controlled by the measures employed. The history is usually only
that of a persistent cough. It may be irritating in character, keep-
ing the child awake at night, or it may be paroxysmal, the attacks
being more severe when the child is lying down. Manv times the
paroxysms are so severe, being particularly worse at night, that
whooping-cough is suspected because of the absence of chest signs.
While we hear much of the cough of teething, the "stomach
cough," the "nervous cough," and the "habit cough," it has never
been my lot to see a case in which the cough was not connected in
some way with the respiratory tract. Thorough examination of these
cases, perhaps repeated examinations, will be required before the site
of the trouble is definitely located, when it will invariably be found
somewhere between the anterior nares and the thorax. The stomach
cough, the nervous cough, or the teething cough formerly stood for
the persistent cough which could not be accounted for by phvsical
examination of the chest or by mere inspection of the throat. They
are frequently referred to by the older writers.
An adherent pleura and enlarged tonsils without adenoids are ac-
countable for a very small number of these cases. An elongated
uvula, to which these obscure coughs have also been attributed, is
very rarely a cause.
An immense majority of these obscure coughs in children are
due to adenoid vegetations with or without enlarged tonsils. A
child with such a cough may have the typical adenoid face, mouth-
breathing, and other signs referred to (see Adenoids, page 426),
or these symptoms may be entirely absent. It is the latter type
of case that is particularly puzzling and apt to be overlooked. On
account of the absence of mouth-breathing and other svmptoms
of nasal obstruction, the possibility of adenoid vegetations has been
ignored. In these cases careful inquiry will usually elicit the his-
tory of frequent colds, or what is styled "catarrh," as there is more
or less serous discharge from the nose, or the child is said to "take
cold in the head easily." Digital examination of the nasopharyn-
geal vault will reveal a fringe of soft adenoid growth at the upper
portion of the posterior pharyngeal wall, not large enough to pro-
duce obstruction, but actively secreting. This secretion, if not
profuse, is partially evaporated in the nostrils, or if profuse, is
discharged from the nostrils or passes backward over the posterior
pharyngeal wall, thus provoking cough, when the child is up and
about. When the child rests on his back, the secretion naturally
flows over the posterior pharyngeal wall, and a cough is the result.
Time and again I have relieved the most obstinate cough by curet-
256 DISEASES OF THE RESPIRATORY TRACT
ting and removing this sponge-like tissue. In one patient, a boy-
two years of age, who had been coughing hard for ten days with
paroxysms and vomiting, a diagnosis of pertussis had been made
by a member of the family who had seen many cases of whooping-
cough, and also by myself. Adenoids were found to be present
in a slight degree. Their removal was advised, with the idea of
making the coughing attacks less severe, when, greatly to our sur-
prise, the coughing ceased at once, not a paroxysm occurring after
the growth was removed. The cough was due to the adenoid vege-
tations and not to pertussis.
Adherent pleura, non-tuberculous, as previously mentioned, is
occasionally a cause of persistent cough. Autopsies upon children
dying with diseases other than respiratory often show these pleuritic
adhesions, which are not suspected during life. A little girl twelve
years of age was brought to me because of a persistent cough. The
child was otherwise well and gaining in weight. She had been
treated with expectorants, cod-liver oil, and the usual medication,
without avail. The cough remained unchanged and was influenced
only by opiates. A very careful physical examination revealed
friction rales, covering an area the size of a half dollar, at the base
of the right lung adjacent to the spine. They were heard only on
forced inspiration and had been overlooked in the previous exami-
nation. It had been diagnosed as a "nervous cough."
Tracheitis will produce a cough, severe and intractable, with
no signs in the chest. In these cases, however, there is no chronic-
ity, the cough being sudden in its development. It is usually
accompanied by slight fever, and if the child is old enough he will
aid us by referring to the sense of discomfort and tightness which
exists over the upper portion of the chest. Sometimes the sensa-
tion will be described as a burning, which is located directly over
the trachea.
The most frequent cause of the temporary cough seen daily
in children's work need only be referred to. It is an acute inflam-
matory condition of the mucous membrane of the respiratory tract,
involving most frequently the fauces, the larynx, and bronchi.
Incipient tuberculous infiltration in any portion of the lungs or
pleura may produce the persistent cough. Thorough physical ex-
aminations and careful observation of all the cases for a few days
will make a diagnosis possible.
Pertussis without the whoop or vomiting may cause a persistent
cough. It runs its course and subsides in from four to eight weeks.
A diagnosis is possible only when there is a history of exposure to
the disease. The treatment for the various conditions producing
cough is referred to under their respective headings.
BRONCHITIS 257
BRONCHITIS
Bronchitis in children may be divided into three types : primary,
secondary, and chronic.
Primary bronchitis is usually the result of exposure. It occurs
in all classes and conditions of children. In New York city it is
a very prevalent disease during inclement weather and is indirectly
the cause of many deaths. Rachitic and otherwise poorly nour-
ished children are particularly predisposed to attacks. The younger
the child, the greater the susceptibility and the more dangerous
the affection.
Secondary bronchitis is most often associated with measles,
whooping-cough, and bronchopneumonia, although it may be a
complication of almost every ailment of early life.
Chronic bronchitis is somewhat rare in young children. It
is seen most frequently in asthmatics, in slow convalescence after
bronchopneumonia, and is always present in chronic pulmonary
tuberculosis.
The onset of an acute attack of bronchitis is usually sudden.
There is cough, followed by fever which is seldom high, occasionally
touching 102° F., but almost never remaining above this point
for any length of time. The usual temperature range is from 100°
to 102° F., the respirations are slightly accelerated, rarely above
thirty per minute, and there is moderate prostration. In a severe
attack the appetite is interfered with, the child is restless, peevish,
and shows general discomfort. Examination of the chest early
in the attack will reveal a harsh, rough respiratory murmur, pretty
evenly distributed all over the lungs. Sonorous, sibilant, and the
various types of mucous rales make their appearance in from
twelve to twenty-four hours. Among thousands of these cases
I have never seen a single uncompHcated bronchitis with a
temperature range above 102° F. When the temperature gets
above this point, or higher, and remains there, there has always
been found a complication of some sort — something other than
the bronchitis to help account for the fever. Often this is tonsilli-
tis, gastro-enteric disturbance, or a beginning bronchopneumonia.
With a temperature ranging above 102° F. and respirations of forty
or over, we may be almost certain of a developing pneumonia.
The duration of an attack of bronchitis is ordinarily stated to
be from five to ten days. This is an error. The duration depends
to a sUght extent upon the child, but to a much greater degree
upon the method of treatment. A primary case properly managed
should be well in five days. Many cases are not treated at all by
the physician, because he is not consulted, and some cases even
then are not properly treated. It is these cases of neglected bron-
chitis which furnish a great majority of our cases of bronchopneu-
17
258 DISEASES OF THE RESPIRATORY TRACT
monia, a disease which contributes largely to the mortality of
children under five years of age.
Signs of consolidation in the lung are not necessary for the
diagnosis of pneumonia. Cases very often reported as capillary
bronchitis, in which there is rapid breathing — 40 to 60 a minute —
high temperature, 103° to 105° F., and marked prostration, show
at autopsy the pneumonic elements which gave during hfe no other
signs in the chest than a diminished respiratory murmur and many
fine mucous rales.
Treatment. — Before indicating what should be done in a case of
bronchitis it may be as important, by way of emphasis, to advise
what not to do. Do not seal the room up tight by keeping all the
windows closed. Do not use an oil-silk jacket lined with wadding or
any other material. Do not allow the child to be wrapped in blankets
and shawls and held against a warm adult body. Do not give the
child large doses of so-called "expectorants" — a teaspoonful of
a heavy syrup. The temperature of the room should be kept as
near 70° F. as possible. There should always be direct communi-
cation with the open air. A window lowered an inch or two from
the top, or the window-board described on page 43, is a safe means
of assisting in ventilation. The child should be kept in its crib
and wear the night-clothing it was accustomed to wear- in health.
Many children with bronchitis do not feel particularly ill and rebel
against the enforced inactivity ; for such as cannot be kept under
the covers, a pinning-blanket or a bath-robe may be worn while the
child sits up in bed, but it should not be allowed to sleep in either.
The Diet. — If there is little or no fever, the diet need be reduced
but Httle. If there is fever, 100° to 101.5° F., with restlessness and
irritability, the food should be reduced in strength, giving the same
amount of fluid as in health, the reduction being made by giving
plain boiled water frequently to drink between the feedings. The
diet of a nursing baby can best be reduced by giving him a drink
of water before each nursing, and shortening the time allowed for
nursing from one-third to one-half. We will thus avoid digestive
disturbances, which often act as a very serious complication to the
existing disorder. Older children, those on a mixed diet, may be
given toast, cocoa, milk, broths, gruels, and fruit-juices.
Steam Inhalations. — Properly administered medicated steam in-
halations are of greater service in bronchitis, particularly in young in-
fants, than anv other measure of treatment which we possess. The
steaming is best administered when the child is placed in its crib, which
is covered and draped with sheets. The croup kettle (Fig. 26) with
alcohol lamp attachment is the most convenient means for genera-
ting steam. The nozzle of the croup kettle, which rests on a chair or
stand, is carried under the tent at a safe distance from the child's
hands and face. For inhalation, creosote has given better results
BRONCHITIS
259
than has any other drug. Ten drops are added to one quart of
boiling water and the steaming continued for thirty minutes. Ordi-
narily, in an urgent case, steaming of thirty minutes is given at
two-and-a-half-hour intervals day and night until the child recovers.
Older children and those in whom the condition is not grave need
not be steamed after the bedtime of mother or nurse. It is well
to allow a change of air in the enclosed space at least three times
during the steaming. This is done by raising the sheet for a
moment or two and then replacing it.
Counter-irritation. — Counter-irritation of the skin over the
thorax is another very useful method of treatment in bronchitis.
Full instructions must be given the mother and nurse as to how the
counter-irritant is to be applied, or the application will be very indiffer-
ently made. In my hands the mustard plaster (page 493) has been
the most convenient means of counter-irritation, and has given the best
results. It is well to begin with a strength
of one part of mustard and two parts of
flour. Two or three applications of this
strength may be made. Later, when the
skin becomes sensitive, the plaster is made
weaker by the addition of more flour, one
part of mustard to five or six of flour.
In order to be effective the plaster should
remain in contact with the skin from five
to fifteen minutes, until a diffuse blush
appears. The plaster is prepared as fol-
lows: Mix the mustard and the flour,
using hot water until a paste of medium
thickness is formed. This is to be spread
on cheese-cloth, old linen, or thin white
muslin, to a thickness of about ^ of an inch.
Over this one thickness of cheese-cloth is placed. The size of the plas-
ter depends upon the age of the child and the area of lung involved.
In a case of general bronchitis the entire thorax, front and back,
should be covered. It is easier to make two plasters which meet
under the arms than to make one to encircle the thorax, as is some-
times done. A circle is cut out for the arms at the upper corners.
The plasters are sufficiently large to meet at the sides, as mentioned
above, when they may be pinned together. When all is completed,
it really amounts to a mustard jacket. The plaster may be applied
from two to four times daily, depending upon the urgencv of the
case. Counter-irritation thus made is of great service early in the
attack — during the stage of acute congestion. I question whether
plasters are of much use after two or three days have elapsed. After
removing the plaster an apphcation of vaseHn is grateful to the
patient.
in. 26. — Croup Kettle with
Alcohol Lamp Attachment.
26o DISEASES OF THE RESPIRATORY TRACT
Mustard Baths. — A mustard bath (page 30), \ ounce of mustard
to 6 gallons of water at a temperature of 110° F., is of considerable ser-
vice in the very acute cases in young children with extensive involve-
ment of the fine tubes — a type of case usually known as "capillary bron -
chitis." These cases are very apt to develop into bronchopneumonia,
if they are not such from the beginning. There is considerable
shock, the hands and feet are often cold, the respiration rapid, and
the child considerably prostrated. The bath may be repeated with
advantage at intervals of from six to eight hours. It will not be of
value after forty-eight hours.
Drugs. — The value of drugs in the management of this disease has
been considerably overestimated, and they are mentioned last because
they are the least important of the remedial measures referred to.
During the first stage of bronchitis, that of engorgement, indicated
by a short, dry cough, and rough, sonorous breathing on auscultation,
small doses of castor oil and syrup of ipecac furnish us our best
medication; from the first to the third year, two to three drops
of castor oil and two to three drops of syrup of ipecac may be
given every two hours; after the third year, three drops of syrup
of ipecac and five drops of castor oil every two hours. At least
eight doses should be given in twenty-four hours. Ordinarily, after
twenty-four hours, auscultation will reveal a freer secretion in the
bronchi, the fever will diminish, and the child's cough will become
loose and less severe. The benefits from the oil and ipecac will be
accomplished in from forty-two to seventy-two hours, when this
medication should be discontinued.
If the cough and the chest sounds tell us that the bronchi are
not yet clear, a combination of tartar emetic, powdered ipecac,
and ammonium chlorid may be used. For a child under six months
of age a powder or tablet containing yio grain of tartar emetic,
gV grain of powdered ipecac, and \ grain of ammonium chlorid should
be given at two-hour intervals, eight doses in twenty-four hours;
from six months to one year, tartar emetic y^^ grain, powdered
ipecac ^V grain, ammonium chlorid \ grain, at two-hour intervals,
eight doses in twenty-four hours. If the cough is very annoying
and severe, requiring a sedative, | grain of Dover's powder may
be added to each dose for children under six months and \ grain
for children over six months of age. From one to three years of
age, tartar emetic y^ grain, powdered ipecac yV grain, ammonium
chlorid \ grain at two-hour intervals, eight doses in twenty-four
hours, h, grain of Dover's powder to be added to each dose if the char-
acter of the cough demands it. The tablet or powder, whichever
is employed, should be given in two teaspoonfuls of thin gruel or
plain water. After the third year -§-V grain of tartar emetic, 2V
grain of pulverized ipecac, and i grain of ammonium chlorid may be
given every two hours, eight doses in the twenty-four hours. The
RECURRENT BRONCHITIS 26 I
use of tablets or powders should be insisted upon, particularly in
very young children. The large doses of ammonium salts and
ipecac in heavy syrups are to be avoided because of their Hability
to produce stomach disturbance.
The treatment of secondary bronchitis depends to a certain
extent upon the disease with which it is associated, and the treat-
ment should be modified accordingly. Counter-irritation and medi-
cated steam inhalations ordinarily can be used, as they interfere but
little with other necessary treatment.
In chronic bronchitis the removal of enlarged tonsils and adenoids,
fresh air, and change to a dry climate, if possible, are our best means
of treatment. In addition, general supporting treatment is to be
advised (see The Management of Delicate Children). Creosote
in small doses, i to 3 minims after meals, for a child from two to
five years of age, has seemed to me to be of service with some of
these children. My greatest success, however, with these cases
has been achieved by ignoring the bronchitis temporarily and put-
ting the child in the best hygienic surroundings. Outdoor life inland
and a nutritious diet are far better than drugs. In many of these
cases, under such a regime, the disease for which the child was brought
for treatment entirely disappeared without any specific medication
whatever, showing that the bronchial catarrh was nothing more or
less than a manifestation of a greatly reduced vitality.
RECURRENT BRONCHITIS
Recurrent bronchitis without the association of asthma is oc-
casionally encountered. A case of this kind was seen by me five
months ago which was so typical that I will give a brief history
of it as taken from my records:
Illustrative Case. — A plump, well-nourished, four-year-old girl
was brought with a history of attacks of bronchitis lasting from
five to seven days at intervals of not longer than three wrecks.
The physical examination was negative. The attacks com-
menced when she was two years of age and had continued for
two years. There never was a temperature of over 100° F. with
the attacks and the child was not physically ill. There had never
been cyclic vomiting, tonsillitis, or rheumatism. The father was
a sufferer from chronic rheumatism. The patient was given a
diet suitable for her age (page 128), meat being allowed every sec-
ond day. She was taking considerable sugar, which was greatly
reduced, only enough being allowed to make the food palatable.
She was given the following prescription:
I^. Sodii salicylatis (wintergreen) gr. xxxvj
Sodii bicarbonatis gr. Ixxij
Elixiris simplicis ov
Aquae q. s. ad gij
M. Sig. — One teaspoonful twice daily after meals.
262 DISEASES OF THE RESPIRATORY TRACT
The above prescription was given for five days, followed by
an interval of five days' rest. This procedure has now been con-
tinued for five months, during which time there has been no bron-
chitis. This period includes the spring and one summer month,
but as the attacks had occurred during the previous summer as
frequently as during the winter, the season of the year cannot be
considered an element in the relief of the patient. As when a child
develops joint or bone disease, the family can usually recall an
injury or fall of some sort to account for the trouble, so also, in the
event of bronchitis, an exposure, a change of clothing, or a change
in the weather will usually be regarded as a cause of the attack.
In the case above cited, and in others also, such factors evidently
have had very little, if anything, to do with the bronchitis, for under
the same climatic conditions the attacks have ceased when atten-
tion was given to the constitutional condition, and proper diet and
medication prescribed. The patients are usually of gouty or rheu-
matic ancestry. Some of them have had growing pains, and others
chorea.
General Management. — The management of these cases is as fol-
lows : The child should lead an active outdoor life when climatic con-
ditions allow. There should always be communication between the
sleeping-room and the outer air. Red meats, including beef, mutton,
and lamb, are given only every second or third day. Sugar is allowed
only in sufficient amount to make the food palatable. If the case
resists treatment, sugar is discontinued and saccharin is substituted.
Skimmed milk is given as a drink, eight ounces being allowed both for
breakfast and supper. Fruits, green vegetables, and cereals well
cooked and suitable for the age are given freely. There must be a
free evacuation of the bowels daily. If there is a tendency to consti-
pation, the oil treatment (page 174) is prescribed. These patients
are not influenced by the usual treatment for bronchitis, so that
expectorant drugs may be omitted. Large doses of bicarbonate
of soda do more toward shortening the attack than does any other
form of medication. For a child five years of age, five grains should
be given at two-hour intervals. The interval treatment with diet
must be relied upon to prevent a recurrence of the attacks. Sali-
cylate of soda (wintergreen) is given for five days, in doses of from
three to five grains, well diluted, after meals. The salicylate is
then discontinued and the bicarbonate is given for five days in the
same dosage, when the salicylate is resumed. In this way, by
alternating the two drugs or by giving aspirin when the salicylate
disagrees, the treatment is continued for months. As the case
improves, an interval of rest from all medication is instituted. If
it is more convenient, the salicylate and the bicarbonate of soda
may be given at the same time. The skin in these cases should be
kept active ; once daily the child should be given a tub-bath in luke-
BRONCHIAL ASTHMA 263
warm water. After the bath, a cool spray or spinal douche is used,
the temperature of the water ranging from 50° to 70° F. An ex-
cessive degree of cold is not advisable; it should be sufficient,
however, to insure good reaction after a brisk rubbing with a rough
towel.
BRONCHIAL ASTHMA
By bronchial asthma in children we understand a condition
characterized by recurrent attacks of bronchial spasm of widely
varying degrees of intensity and duration, toxic or reflex in origin,
associated either with an involvement of the nasopharynx or the
bronchial mucous membrane in the form of turgescence or inflam-
mation. I have come to divide my cases of asthmatic children
into two classes. To the first class belong comparatiyely few:
those in whom paroxysms are produced by direct irritation, as
by the pollen of plants or the odors of animals or flowers, which
produce what is known as "hay-fever " and the associated asth-
matic condition. Hay-fever is rarely seen in children under five
years of age. In by far the greater number of my patients, which
constitute the second class, who have suffered from asthma there could
be discovered the so-called " lithemic diathesis"; in other words,
there was a gouty or rheumatic association. Among these, cases of
recurrent bronchitis (page 261) and asthma are included. In not
a few cases of recurrent bronchitis there is asthma of such a slight
degree that it may escape observation. In others it is entirely
absent. Repeated acute attacks of asthma give rise to pulmonary
emphysema which emphasizes the necessity of early medical treat-
ment. I have two patients under m.y care, both under ten years
of age, who are hopeless invalids because of marked emphysema
due to repeated attacks of asthmatic bronchitis. Both cases were
neglected in their early management. In the Hthemic type the
attacks sometimes occur with such regularity as to suggest the
"explosion " seen in cyclic vomiting. Enlarged tonsils and adenoids
may exist as accessory exciting causes. Otherwise they cannot be
looked upon as etiologic factors.
Illustrative Case. — A girl eight years of age was brought to
me three years ago with the history of an attack of asthmatic
bronchitis everv month for several years. The asthma was not
severe. It was present at the onset of the attack and lasted
perhaps for twenty-four hours. The bronchitis usually cleared up
in about five days. She had spent but little time in New
York because of her so-called frequent "colds." Her mother
brought the child to me in view of a contemplated change of resi-
dence. In Florida and Lower California, where she had passed the
winter, the attacks had occurred, but were mild in character. As
soon as she returned home the attacks returned, keeping her from
264 DISEASES OF THE RESPIRATORY TRACT
school for one week out of every four or five. In taking the per-
sonal history, the matter of adenoids and tonsils was mentioned,
when the mother hastened to inform me that the adenoids and tonsils
had been removed twice, thus demonstrating that they were not a
factor in the case. The child had never suffered from rheumatism
or cyclic vomiting. Aside from revealing a mild secondary anemia
and slight emphysema the physical examination proved negative.
As to her family history, I learned that all of the child's antecedents
on both sides, for three generations, had suffered either from rheu-
matism or gout. Her mother had been a lifelong sufferer from rheu-
matism. Upon close questioning as to the child's diet, it was found
that it consisted of red meat twice daily; she "hated " vegetables,
took cereals only when "loaded " with sugar, and drank milk only
when two teaspoonfuls of sugar were added to each glass. She
had candy and cake ad libitum. She was recovering from an attack
of bronchitis when I saw her, and was taking an expectorant cough-
syrup. This was discontinued, red meat was permitted but twice
a week, the sugar was largely reduced, saccharin being used in the
milk to satisfy the abnormal craving for sweets. She was bribed
by the mother to eat green vegetables and cereals. The desserts
consisted largely of stewed fruits flavored with saccharin. Candy,
cake, and pastry were forbidden. She was given four grains of the
salicylate of soda (wintergreen) three times daily for five days,
which was followed by ten grains of the bicarbonate three times daily
for five days. This treatment was continued for six months, during
which time the salicylate was given for five days, the bicarbonate
for five days, and no medication whatever for five days, when the
procedure was repeated. During the following six months the
salicylate and the bicarbonate of soda were given but ten days out
of each month, and during the entire year but one mild attack of
bronchial asthma occurred.
Treatment. — The management of bronchial asthma consists of
care during the attack, and the interval treatment, the latter being
by far the most important. In infants and young " runabouts " with
this type of trouble, there is usually considerable bronchitis, and this
requires our attention. I have found, in addition to the usual
laxatives, calomel or castor oil, that a combination of syrup of
ipecac, antipyrin, and bromid of soda gives the most prompt results
as far as internal medication is concerned. For a child six months
of age the following prescription has been found useful :
I^. Syrupi ipecacuanhae gtt. xviij
Antipyrina? gr. vj
Sodii bromidi gr. xviij
Syrupi rubi idaei 5 v
Aquae q. s. ad o ij
M. ft. Sig. — One dram every two hours — six doses in twenty-four
hours.
BRONCHIAL ASTHMA 265
For one year of age:
1}. Syrupi ipecacuanhas gtt. xxiv
Antipyrinse gr. xij
Sodii bromidi gr. xxiv
Syrupi rubi idaei 5v
Aquae q. s. ad 5ij
M. ft. Sig. — One teaspoonful at two-hour intervals — six doses in
twenty-four hours.
For a child from two to three years of age:
J^. Syrupi ipecacuanha? gtt. xxxvj
Antipyrinae gr. xviij
Sodii bromidi gr. xxxvj
Syrupi rubi idaei ov
Aquae q. s. ad 5ij
M. ft. Sig. — One teaspoonful in water, at two-hour intervals — six doses
in twenty-four hours.
In addition to the internal medication, the child will often be
greatly relieved by stimulant inhalations as described under Spas-
modic Croup (page 249). If the condition is urgent, the inhalations
may be given for thirty minutes with thirty minutes' rest. Mus-
tard in the proportion of one part of mustard to two parts of flour
(page 259), so applied as to envelop the entire thorax, will often
relieve the spasm sufficiently to reduce the respirations from ten
to twenty a minute. The mustard should remain on long enough
to redden the skin and should not be repeated oftener than once
in four hours. The cold-air treatment in bronchial asthma is con-
traindicated, regardless of the age of the patient. Warm moist
air at from 68° F. to 70° F. is best. A sudden blast of cold air may
be sufficient to increase the severity of the paroxysms to a marked
degree. Ventilation, however, is a necessity in these cases. The
best means of obtaining it is by the use of two rooms, one of which
may be aired while the other is occupied. Before the child is changed
to the aired room, its temperature should be raised to that of the
other.
In older children after the fifth year the bronchial spasm may
be considerable, and more active measures may be required to fur-
nish temporary relief. Here the methods usually employed for
the same purpose in adults may be brought into use. A few whiffs
of chloroform will often be effective. Fumes of nitrate of potash
paper will sometimes be of service. At this age, also, a combination
of antipyrin and bromid of soda may be brought into use. For a child
from five to ten years of age, three grains of antipyrin with from
six to ten grains of bromid of soda, repeated in two hours, will often
be followed by a cessation of the paroxysm. As soon as the spasm
subsides the sedatives should be discontinued. I have never found
it necessary to give morphin hypodermatically or otherwise in these
cases. In a very severe case, in a girl eight years of age, a com-
bination of antipyrin and codein in full dosage was required to
266 DISEASES OF the; RESPIRATORY TRACT
control the paroxysms. She was given one-fourth grain of codein
and four grains of antipyrin at two-hour intervals until three doses
had been given.
The interval treatment for the bottle-fed consists in a reduction
of the sugar to one-half the amount suitable for the age and the
use of one grain of bicarbonate of soda for each ounce of the milk
food given. The bowels must be kept properly open, although
constipation or intestinal toxemia has never appeared to me to be
an important factor in asthmatic children. The interval treat-
ment for older children is most important, for by it we are able to
postpone the attacks. These cases, as I have indicated, are usually
in lithemic subjects, and the scheme of management followed out
is the same as for rheumatism, chorea, recurrent bronchitis, and
cyclic vomiting. Sugar is reduced to a minimum, red meat is given
not oftener than every second day, and then only in moderate
amounts. The child's proteid nutrition is maintained by the use
of a high-proteid cereal, such as oatmeal, and purees of dried peas,
beans, and lentils. The eating of green vegetables is encouraged.
Food between meals is forbidden. Fruits are used in moderation
and an active outdoor life is encouraged. At bedtime the child
is given a brine bath (page 31), followed by a vigorous dry rub.
The mother or attendant is instructed that one bowel evacuation
daily must be insured. The medication consists of bicarbonate
of soda, from five to ten grains a day for five days, alternating
with the salicylate of soda (wintergreen) in doses of from three to
five grains three times a day. This is continued for a month or
two until its effect on a recurrence is noted. If the salicylate of
soda disturbs the digestion, the same quantity of aspirin may be
given. The further continuation of the medication depends upon
the effect produced. Usually in two months the salicylate may
be given in smaller doses. Interrupted medication, however, should
be continued for several months. When my cases with a bad family
history have been relieved, I continue the diet permanently, giving
the medication for but five or ten days and then omitting it for
sixty or eighty days, when it is again given for a short time, con-
tinuing thus for as long as may be thought best in the individual
case.
BRONCHOPNEUMONIA; CATARRHAL PNEUMONIA
Catarrhal pneumonia, on account of its large mortality, and
because of its frequent appearance as a complication of almost
every disease of infancy, is one of the most formidable ailments
which we are called upon to treat. The disease is usually described
as primary or secondary. Among the several hundred cases which
have come under my observation comparatively few — less than
5 percent — were primary. Those described as primary usually
bronchopneumonia; catarrhal pneumonia 267
follow a bronchitis, often a neglected bronchitis. The disease
varies considerably as regards its severity, depending on the age
and condition of the child, the nature of the infection, and the amount
of lung involved. It is most fatal when associated with diphtheria
or measles.
Catarrhal pneumonia demands our most careful attention,
not only on account of the delicate organs attacked, enclosed in
weak thoracic walls, but because — unlike lobar pneumonia, scarlet
fever, typhoid fever, and many other diseases of early Ufe — it has
no self -limitation, no cycle. While in the other diseases mentioned
we are required only to assist a patient through the various stages,
in catarrhal pneumonia we must do more, for here a cure is demanded.
Treatment. — Every child at the commencement of an illness has a
definite resistance to it. In catarrhal pneumonia, for the reasons just
given, it. must be our effort to preserve every strength unit which
the child possesses. An immense amount of vitality is wasted in sick
children because of irritability, restlessness, and loss of sleep. One
of the first duties in a given case is not to give this or that drug,
or use this or that local application, but to make the child com-
fortable— to put him in the best position to withstand disease.
We must establish a sick-room regime which will make this possible.
The Sick-room. — The value of a constant supply of fresh air is
too little appreciated. In every case there should be a direct com-
munication between the sick-room and the open air, throughout the
attack. Various means of ventilation have been devised, of which
the window-board (page 43) is the most effective, as it separates
the sash and allows the free entrance of a current of air which is
directed upward. If plenty of fresh air at a proper temperature
were available during the early part of the illness, there would be
much less use for tanks of oxygen later.
An absolute necessity in a sick-room is a good thermometer.
In pneumonia cases it should never register above 70° F. There
is marked tendency to coddle, to wrap, to overclothe, pneumonia
patients. The patient requires, even during the winter, absolutely
nothing more than a medium- weight flannel shirt, a band, if one
is ordinarily worn, and the usual night-dress. Some years since I
discarded the oiled silk jacket. It is cumbersome, it is impossible
to keep clean, and it overheats the patient. Given an infant with
catarrhal pneumonia, have him heavily clad, keep him in an unven-
tilated, overheated room, in close contact with an adult body, and
you have a patient who is tremendously handicapped. There is
but one place for a sick infant, and that is in his own roomy crib.
Diet. — In every illness with fever, the digestive capacity is con-
siderably reduced. If the usual milk diet is continued, we are very
liable to have a gastro-enteric infection added, oftentimes as a serious
complication, to the existing disease. In the breast-fed a drink
268 DISEASES OF THE RESPIRATORY TRACT
of water is ordered for the child before the nursings and between
them. The nursing hours should be the same as in health, but the
time allowed for each nursing should be reduced from one-third to
one-half. In the bottle-fed the milk strength should be reduced
from one-third to one-half by dilution with water, the quantity re-
maining the same. Children from two to four years of age are put
on a diet of diluted milk, gruels, and broths.
Bowels. — Normal bowel function is more necessary for the sick
than for the well. There should be at least one stool in twenty-four
hours.
General Treatment. — Having placed the child under the best
dietetic and hygienic conditions, we are in a position to use medi-
cation to a much better advantage. But in its use, and in perform-
ing the various offices for the patient, it must be our effort to disturb
him as little as possible. In our anxiety to do, we are very liable to
overdo, with disastrous results. If a well child were given syrup ex-
pectorants, stimulants, baths, and local applications, something being
done for him every hour or two in the twenty-four, he would have
to be a strong child to withstand the treatment. We should treat
our ill with still greater consideration. Make the intervals between
which the child is to be disturbed at night as long as possible by
giving food, medicine, and local treatment at one time. When
possible, I always endeavor to make the interval at least three hours.
Steam Inhalations. — Among the distinctly remedial measures,
aside from those administered internally, steam inhalations with creo-
sote deserve an important place. The patient is placed in its crib,
which is covered and draped with sheets so as to make a fairly tight
enclosed space. The apparatus necessary is an ordinary croup kettle
(see page 248). Ten drops of creosote are added to one quart of
water and placed in the kettle. The nozzle of the kettle is intro-
duced between the sheets at a safe distance from the child's face
and hands, the steaming being carried on for thirty minutes every
three hours. The sheets should be parted shghtly about every ten
minutes, to allow a renewal of the air. The inhalations are to be
given whether the patient is sleeping or waking. As he improves,
they may be given less frequently until normal respirations and the
chest signs tell us they are no longer required.
Counter-irritants. — The application of counter-irritants to the skin
over the thorax is, to my mind, of great service in cases in which there
is much bronchial catarrh, which includes, of course, most cases. In
order that a counter-irritant may be of service, a distinct red blush
must be produced on the skin. Turpentine diluted with oil, — one-
third turpentine and two-thirds oil, — when briskly rubbed on the parts
for a few minutes, produces a fairly satisfactory counter-irritation.
The old-fashioned home-made mustard plaster has served me well
as a counter-irritant. Written directions should always be given
bronchopneumonia; catarrhal pneumonia 269
for the preparation of the plaster, and the boundaries of the area of
the skin to be covered should be outlined with a pencil on the
skin's surface. If the nurse or mother is told merely to put a mus-
tard plaster on the chest, a plaster the size of a man's hand will
usually be placed somewhere between the umbilicus and the chin!
For the first two or three applications one part of mustard to two
parts of flour is used. This is moistened with hot water and made
of the consistency of a rather thin paste, which is then spread upon
cheese-cloth, old muslin, or linen, cut to the desired size. The plas-
ter is readily held in position by a bandage of any thin material
extending around the chest. When the skin is well reddened,
usually within from five to fifteen minutes, the plaster is removed
and vaselin or sweet oil applied. I never use a plaster oftener
than once in six hours, and then only in the severest cases. Ordi-
narily, two or three applications in twenty-four hours are sufficient.
If the plasters are continued for several days, in order to avoid
blistering, it will be necessary to make them much weaker after a
day or two — one part of mustard to five or ten of flour. Counter-
irritation is particularly effective when used at the commencement
of an attack.
Mustard Baths. — In cases of sudden onset, wdth high fever, rapid
breathing, and cold extremities, a mustard bath — one tablespoonful
of mustard to six gallons of water at 100° F. — will often furnish
marked relief to the immediate symptoms. Autopsies on these cases
show a general congestion of the internal organs, wdth intense con-
gestion of the lungs. The bath may be repeated at six-hour inter-
vals. This type of case is usually very rapid in its development, the
child being relieved or dead in from thirty-six to forty-eight hours.
By "relieved " we do not mean that the child has recovered, but
that the acute urgent symptoms have subsided. In my opinion
only these cases should be considered primary.
Drugs. — The internal medication is, to a large extent, sympto-
matic. In any disease a great deal of harm may be done to young
children by the thoughtless use of drugs. In catarrhal pneumonia it
is particularly necessary that, in our endeavors to assist the patient,
we do nothing to harm him, for we are treating a disease in which
his powers of resistance count for everything. In young children,
even in health, the digestive functions are very easily disordered.
In illness with fever, with the accompanying nervous exhaustion,
the stomach is most easily disturbed, the child is not properly nour-
ished, and his powers of resistance are markedly diminished.
Expectorants must be given with care and are better prescribed
in the form of tablets or powders. The use of heavy syrups of
wild cherry, tolu, etc., with large doses of the ammonium salts,
only adds to the burden of the patient. For a child one year
of age with catarrhal pneumonia, y^o grain of tartar emetic and
270 DISEASES OF THE RESPIRATORY TRACT
4V grain of ipecac answer well as an expectorant. If the cough is
very severe and persistent, | grain of Dover's powder in tablet form
with sugar of milk dissolved in at least two teaspoonfuls of water,
may be given, preferably after feeding, not oftener than once in
two hours. The ammonium salts so generally used in catarrhal
pneumonia as routine treatment are badly borne by the stomach.
The muriate of ammonia is of some value during resolution, but
to a child two years old. it should not be given in larger doses than
^ grain well diluted, at two-hour intervals; personally, however,
I rarely use it. With high fever and great restlessness, which are
not affected by sponging, and where for any reason rational bath-
ing is impossible, a combination of caffein, Dover's powder, and
phenacetin may be used. For a child one year of age I would give
i grain of caffein, ^ grain of Dover's powder, and i^ grains of phen-
acetin at about four-hour intervals. In giving Dover's powder it
is well to watch the bowels, as constipation often follows its use.
Heart stimulants are usually necessary, and in their selection
two points are to be considered — their effect on the heart and their
effect on the stomach. But, first, what are the indications for the
use of a heart stimulant? Ordinarily, I think, they are used too
early. A heart stimulant should never be given simply because
a child has pneumonia or diphtheria or scarlet fever, but it should
be given in pneumonia or diphtheria or scarlet fever as soon as
the heart needs assistance. And, briefly, there are two conditions
to guide us, a very rapid pulse or a soft, usually not rapid, pulse
with a tendency to irregularity. In a general way, I believe that a
heart which is beating at the rate of 1 50 a ininute during quiet or sleep,
and which is not strengthened by sponging or packs, needs assistance,
and the drug which has served me best is tincture of strophanthus,
which acts as a direct stimulant to the heart muscle. The pulse,
by its use, is made stronger, fuller, and less rapid. When the heart's
action shows a tendency to irregularity, with a soft, easily com-
pressible pulse, then strychnin is the remedy. For a child one
year of age one drop of strophanthus in water may be given every
three hours, or -3^0 grain of strychnin every three hours, to be in-
creased to Yoo^ or even to y^^ grain every three hours for a few
doses if the case is carefully watched for symptoms of strychnin
poisoning. Strophanthus and strychnin possess advantages over
all other stimulants in that they do their work and have no un-
pleasant effect on the stomach, as is the case with alcohol, digitalis,
and the ammonium preparations. If the condition is very urgent,
strophanthus and strychnin may be used in combination. Digi-
talis I rarely employ because of its tendency to interfere with diges-
tion. Alcohol in the form of whisky or brandy is very rarely of
great service in catarrhal pneumonia. It may stimulate the heart,
but its prolonged use greatly upsets the stomach. It should be
bronchopneumonia; catarrhal pneumonia 271
withheld until late in the disease, when other means of stimulation
fail. Then, given in large amounts, it may be the means of saving
the patient. One-half dram of whisky or brandy, well diluted,
may be given every hour or every two hours to a child one year
of age. However, the cases of catarrhal pneumonia actually saved
by the use of alcohol are few indeed. One one-hundredth grain of
nitroglycerin every three hours for a child one year of age is of service
in cases where there is marked cyanosis with cold extremities. Its
use should be discontinued as soon as improvement in this respect
is noticed. The one unpleasant effect that I have observed from
its administration is its tendency to produce headache and marked
restlessness.
Baths. — A sponge-bath at 95° F. for cleansing purposes may be
given daily.
What is to be our guide in dealing with the temperature? At
what degree of temperature are we to interfere, the rectal temper-
ature alone being considered? This depends to a great extent
upon what is behind the fever and the effect of the fever upon the
individual patient. If a child has a high fever and is more com-
fortable when it is reduced, — if he will digest his food better and
sleep better, — it is our duty to reduce it. Further, by reducing
the temperature we lessen the work of the heart, saving it often-
times many beats a minute. Usually when the temperature has
a tendency to run above 104° F., interference is of advantage, and
the best means at our command is the use of local applications of
water in the form of sponge-baths or packs. If the temperature
is easily controlled, a sponge-bath will answer our purpose. Either
salt or alcohol may be added to the water. Ordinarily two teaspoon-
fuls of salt to a quart of water, or one part alcohol to three parts
water, is ample. Cold water thus used serves two purposes — it
acts as a sedative and it reduces the fever. Cold sponging, while
not controlling the fever as effectually as does a bath or a pack,
possesses the advantage that the most unskilled can use it. For
sponging, the child should be stripped and covered with a flannel
blanket, the sponging being done under the blanket. In order
not to antagonize or frighten the child, it is best to begin with the
water at 95° F. and gradually to reduce it to 70° or 75° F. by the
addition of ice or cold water. The sponging may be continued from
ten to twenty minutes, and should not be repeated at shorter intervals
than ninety minutes. After the sponging is completed the skin
should be rubbed briskly for a few minutes with a dry towel. If
the temperature is not readily controlled in this way, it is best to
use other means, as too frequent sponging exhausts the patient.
As a means of controlling the temperature in children, the tub-bath
has not been successful in my hands, for the reason that I have not
been able by this means to control the fever. The exposure, the
272 DISEASES OF THE RESPIRATORY TRACT
fright, and the necessary shortness of the bath render it very unsatis-
factory.
Cold Pack. — By far the best means at our command for controlUng
a continued high fever is by the use of the cold pack (page 481).
Properly applied, it is without the slightest danger. It is prepared
as follows : A large bath-towel or any thick absorbent material may
be used, slits being cut in one end of the towel through which the
arms may pass. The towel is folded over the body, and should extend
from the neck to the middle of the thighs ; the arms and the legs from
the knees down should remain free; a hot-water bag, carefully
guarded, should be placed at the feet. The towel is moistened with
water at 95° F. It is well to make the pack warm at first, so that the
child will not be frightened, as shock will thus be avoided. I have
known severe shock to follow in a case where a child with a tempera-
ture of 105° F. was put suddenly into a pack at 70° F. In two or three
minutes the towel is moistened with water at 85° F., then at 80° F.
When 80° F. is reached, it is best not to make the water any colder
for half an hour, at which time the temperature of the patient is
taken. If, in the beginning, it was 105° F. and then shows a slight
or no reduction, the temperature of the pack may be reduced to
70° or even to 60° F. by the addition of cold water or ice, without re-
moving the child, who is turned from side to side so that all
parts of the enveloping towel may be moistened with the cool water.
During the first hours in the pack, the temperature should be taken
every half hour, and when it is reduced to 102° F., the child is removed
and wrapped in a warm blanket. In cases of sudden and persistent
high fever, the child may be kept in the pack continuously. We
aim to keep the temperature between 102.5° and 103.5° F. The
degree of cold necessary to control the fever in a given case will soon
be learned. I recently kept in a pack for seventy-two hours a four-
year-old boy, ill with lobar pneumonia. In this case a pack at 70° F.
was necessary to keep the temperature at 104° F. or slightly lower.
A fresh towel should be applied every three hours. An ice-bag
should be kept at the head, a hot-water bag at the feet, and the
patient covered with a flannel blanket of medium weight.
Oxygen. — Oxygen is of immense ser\nce in very severe cases with
much lung involvement. It may be given continuously for one or
two minutes out of every seven or ten. As often given, one or two
minutes every half hour, it is of little or no service.
LOBAR PNEUMONIA
The onset of lobar pneumonia is usually sudden. In about
3 percent of the cases it is ushered in by a convulsion. In older
children, those past the third year, there may be an initial chill.
There is almost always high fever from the beginning of the attack.
The face is flushed, the lips are separated and parched, and the
LOBAR PNEUMONIA
273
child usually breathes through its mouth. The respiration is markedly
accelerated, — forty to sixty per minute, — the end of each inspira-
tion being marked by a peculiar sigh or groan. At this time there
may be in the chest no discernible signs of the disease. The respir-
atory murmur over the entire thorax is rendered harsher than nor-
mal, but this is caused by the rapid respiration. Bronchial breath-
ing and bronchial voice may be delayed until the fourth or fifth
day, although they are usually present within forty-eight hours
from the onset of the acute symptoms. In a case seen recently,
signs of consolidation did not appear until the seventh day of the
disease, and on that day the crisis occurred. It was objectively
a typical case of lobar pneumonia, but without chest signs until
the seventh day. A case of this type is usually referred to as a
"central " pneumonia; the consolidated area being deep in the
lung tissue, and covered by normal lung, cannot be made out.
The temperature at the onset will usually be from 103° to 105° F.
In an average case the temperature range throughout an attack
is from 103° to 105° F.
Lobar pneumonia is a distinctly infectious disease terminating,
in recovery cases, by crisis. The crisis may be looked for any time
after the third day of the disease, though it seldom occurs before
the fifth day, the usual time being from the fifth to the ninth
day of the disease. A crisis delayed beyond the ninth day means
a very serious infection and a very grave prognosis. I have had
recovery cases in which the crisis did not occur until the eleventh
day, one on the thirteenth, and one on the fifteenth day. In eight
fatal cases in the New York Infant Asylum, two died on the eighth
day, two on the ninth, two on the twelfth, one on the twenty-first,
and one on the tvventy-fourth day of the disease.
Among the out-patient poor, lobar pneumonia frequentlv runs
its course unrecognized. At the outdoor service of the Babies'
Hospital we not infrequently have cases brought to us with lobar
pneumonia in the stage of resolution. The child had a hacking
cough with fever, and was supposed to be suffering from a cold or
an attack of influenza. There was evidently no pain, hence nothing
was suspected. In children localized pain in the chest is often
absent throughout the entire attack.
Lobar pneumonia runs a limited course, with a strong tendency
to recovery. It is a disease which children bear well, under proper
management — a disease for which there is no specific treatment,
and our efforts in restoring the patient to health are supportive
only, so that the patient may be enabled successfully to withstand
the disease.
Treatment. — When a child is stricken with lobar pneumonia we
know that his physical strength is to be severely tested, and our
first effort should be to place him in such a position that he may
274 DISEASES OF THE RESPIRATORY TRACT
to the best advantage cope with the enemy. In order to do this,
every detail of his daily life should so be arranged as to place all
the organs of the body in the most favorable position to meet the
changed conditions produced by disease. Telling the mother what
to do for the fever and writing a prescription for a cough mixture
is a most careless way of treating pneumonia; it is the method
of the prescribing apothecary; physicians never do it. A proper
regime must be established as soon as the child becomes ill. The
bowel function, the room-temperature, ventilation, and sleep, as
well as special medication, are to be considered. The child must
be kept as comfortable as the conditions allow, and his comfort
means the avoidance of everything causing restlessness or irri-
tability, which throws more work upon the heart and diminishes
his resistance to the disease.
The Sick-roam. — Being usually a winter disease, the temperature
of the room and the ventilation demand special attention. The tem-
perature of the room should be kept at 70° F., or very near that figure,
both day and night. Wide fluctuations in the temperature should
not be allowed. A child with lobar pneumonia needs the best air
that can be furnished. A large room, if at hand, should always be
selected, and there must always be a direct communication with
the open air. A window-board (page 43) is a convenient means
of ventilation. The child should be kept in its crib, and not held
on the lap of the mother or nurse.
Quiet should be maintained- in the sick-room, only those in
attendance upon the patient being allowed there. A sick-room is no
place for visitors and otherwise curious persons. Their presence
annoys the child and takes away just so many strength units, which
may determine the question of life or death.
The Clothing. — The clothing should be the usual night -clothing.
I have long since discarded the oiled-silk jacket or any special means
of covering. The oiled-silk jacket or a jacket made of cotton wad-
ding is very easy to put on, but very difficult to take off with safety;
further, it has a tendency to elevate the temperature of the patient,
it makes him uncomfortable, particularly during convalescence,
and prevents the free action of the skin. These objections, with
the fact that there is no rational argument for its use, are sufficient
to condemn it.
The Bowels. — The patient's bowels should move once or twice
daily. There should be a standing order with the nurse or mother
for an enema to be given if the bowels do not move once in twenty-
four hours. One-half to one grain of calomel in doses of one-sixth
of a grain every hour is usually of considerable service. In a case
in which there is very high fever I often order the dose repeated
every three or four days.
Counter-irritation . — Counter-irritation of the skin is of but little
LOBAR PNEUMONIA 275
service in lobar pneumonia. Early in the attack, when there is pain,
a mustard plaster, — one-third mustard and two-thirds flour, — mixed
to a paste, spread on cheese-cloth, and placed over the involved area
will give signal relief. It may be repeated at intervals of from four
to five hours. This form of counter-irritation is also useful in
convalescence in delicate children when the lung clears slowly.
The examination of these cases usually reveals feeble breathing
and many mucous rales. In such cases two or three applications
daily until the lung clears will answer. The application should be
kept on until the skin is well reddened. If this does not take place
in ten minutes, the mixture of mustard and flour should be made
stronger — one-half mustard to one-half flour. In a few cases with
delayed resolution, two dry cups daily, applied directly over the in-
volved areas, have been of much service.
The Diet. — See Diet in Illness, page 133.
Antipyretics. — Whetherornot antipyretic measures are to be used,
and the nature of the antipyretic to be advised, depends upon the case
and the family possibilities as to care and nursing. One child will bear
a temperature without inconvenience which would seriously compro-
mise the chances of recovery of another, so that the thermometer is
not the only guide. The eflfect of the fever upon the patient must
guide us. Some children will be delirious and restless at 103° F.
and will need antipyretic treatment. A temperature of 104° F.
rarely needs interference. A rise of one degree F. will usually mean
an increase of twenty to thirty heart-beats per minute. In lobar
pneumonia, I prefer that the temperature should not go above
105° F., even if at the time the child shows but httle inconvenience.
Such a temperature means an unnecessary increase in the amount
of work required of the heart, which instead demands relief in such
an emergency.
Cold water, when it can be intelligently applied, is the best
means of reducing fever. It may be used either in the form of a
sponge-bath or a cool pack. The sponge-bath (page 30) answers
in a few cases in which the temperature is readily influenced. It
may be repeated at intervals of from two to four hours. As a rule,
the cool pack (page 481) will be required, especially if the fever
is particularly high. The sponge-bath, while not controlHng the
fever as well as does the pack, possesses the advantage that the
most ignorant can safely use it. It really amounts to nothing more
than sponging the entire body with cool water or alcohol and water.
The cool pack requires a trained nurse or a very intelligent mother,
either of whom should be instructed by the physician as to its use.
When properly applied, and when the packs or baths agree, prompt
improvement in the immediate symptoms follows their use; the
child, previously restless, and perhaps delirious, falls into a quiet
sleep. The temperature falls two or three degrees, the pulse becomes
276 DISEASES OF THE RESPIRATORY TRACT
slower and fuller, the respiration less frequent, and when properly
given, I have never seen a pack or bath do harm to a child. In
fact, they are most grateful to the patients, who, when old enough,
have asked to have the towel made cooler when it became warm
and dry from the heat of the body.
Heart Stimulants . — A child must never be given a heart stimulant
simply because he has pneumonia. Heart stimulation is usually em-
ployed too early in the attack. When the pulse shows signs of
weakness, whether by its rapidity, its irregularity, or its reduced
volume, then it is time for stimulants. For a very rapid pulse, i. e.,
over one hundred and fifty, tincture of strophanthus has answered bet-
ter in my hands than any other means of stimulation. For a child
from six months to one year old, I order one drop every two hours — at
least six doses in twenty-four hours; for a child from one to three
years old, one or two drops at intervals of two hours — at least six
doses in twenty-four hours; for a child of three years or over, two
or three drops at intervals of two hours — at least six doses in twenty-
four hours. If the case is a very serious one, the strophanthus
may be given every two hours during the entire twenty-four; but,
if the conditions permit, it is better to disturb the patient as in-
frequently as possible during the night.
When the pulse is irregular and intermittent, with reduced
volume, then strychnin is the remedy. For a child from six months
to a year old, -g^^- grain is to be given every three hours — six doses
in twenty-four hours; from the first to the second year, ^^-^ grain
at three-hour intervals — six doses in twenty-four hours; after the
second year, yio" grain may be given at intervals of three or four
hours — six doses in twenty-four hours. Children who are under
strychnin medication should be carefully watched for signs of the
physiologic effects of the drug ; the first symptoms being an unusual
susceptibility to sudden noise and a slight fibrillary twitching of
the muscles of the face and the backs of the hands. Instructions
should be given, when these symptoms appear, to discontinue
the drug until the next visit of the physician. I have repeatedly
noticed these signs of the physiologic effects of the administration
of strychnin, and they need cause no anxiety; in fact, they are
necessary in order to get the full benefit of the drug. However,
it is only in the most severe cases that the drug should be pushed
to such an extent.
When the circulation of the skin is deficient, with cold extremi-
ties and cyanosis, indicated by blueness of the finger-nails and
lips, nitroglycerin is indicated. For a child under one year of age,
•3^ grain may be given at intervals of two or three hours — six
doses in twenty-four hours ; for a child from one to three years of age,
g-g-g- grain at three-hour intervals — six doses in twenty-four hours;
after the third year
LOBAR PNEUMONIA 277
doses in twenty-four hours. Nitroglycerin, if given in large doses,
produces headache, of which older children will complain, and
nurslings will show their discomfort by restlessness and crying.
Digitahs is rarely used as a heart stimulant in young children.
It disturbs the stomach and the remedies mentioned above meet
the conditions much better. The ammonium preparations are
not employed because their administration even for a short period
invariably interferes with nutrition by diminishing the digestive
capacity.
Camphor and musk, recommended by some, have a very tran-
sient stimulating effect, and in my hands have been ineffective.
Alcohol is often prescribed too early in pneumonia in children.
Many of my cases of pneumonia pass through an entire attack
without one drop of alcohol. Alcohol in any form should be avoided
early in the disease. Later, when the case is doing badly, when the
strychnin and strophanthus, alone or in combination, fail, then
alcohol may be given, and then it may be a Hfe-saving measure.
It is indicated at this time because it sustains the patient when
regular food assimilation is impossible, and at the same time it
stimulates the heart. Under one year of age I give from eight
to thirty drops of brandy, at two-hour intervals; from one to two
years of age, fifteen drops to one dram at two-hour intervals; over
two years, one to two drams at two-hour intervals. Cases which
show profound sepsis will require and consume an enormous quan-
tity of alcohol without showing the slightest intoxicating effect.
When resident physician of the New York Infant Asylum, a child
fourteen months of age ill with diphtheria was given four ounces
of brandy in twenty-four hours without showing signs of stupor
or intoxication.
Hypodermic Stimulation. — -The use of hypodermic stimulation in
children is to be advised onlv in an emergencv, or when the stomach
becomes intolerant. If the dietetic means suggested are carried out,
and if disturbing drugs such as the ammonium salts, heavy syrups,
etc., are omitted, there will rarely be any occasion to resort to hvpo-
dermic stimulation. But when indicated the doses suggested for
the stomach may be given hypodermically, with the exception of
alcohol, which should not thus be given in quantities greater than
one-half dram of brandy or whisky at one time.
Cases will be encountered in which, on account of the profound
toxemia, no food or medicine will be taken. Here the giving of
stimulants and predigested food by means of gavage (page 135)
will be of material assistance. The milk used should be completely
peptonized, and to it whisky, brandy, and stimulating drugs may
be added. The forced feeding should not be used oftener than once
in four hours, usually once in six hours is preferable. When thus
given the amount of the stimulants should be increased.
278 DISEASES OF THE RESPIRATORY TRACT
Colon flushing (page 496) with a normal salt solution, at 110°
F., is of great service in pneumonia when there is extreme pros-
tration. A pint or more of the solution may be used alone or com-
bined with one-half dram of brandy or whisky. The fluid should be
carried high up into the descending colon. As the rectum soon
becomes intolerant, the flushing should not be repeated oftener than
once in six or eight hours.
Specific Medication. — There is no drug known which will cut
short or abort an attack of lobar pneumonia. Mercury in the
form of large doses of calomel, quinin, salicylate of soda, and other
drugs have no specific action. As previously stated, our efforts
must be directed tow^ard a conservation of the strength of the patient
by placing him in the best position to cope with the disease. This,
with careful medication to meet special requirements as they arise,
constitutes our treatment of lobar pneumonia, and has given us
a death-rate of only 2 percent in children under two years of age.
During convalescence great care is needed as to permitting the child
to resume his usual habits of life, for in these matters, as well as
in regard to food and exercise, we must make haste slowly.
PRIMARY PLEURISY
Acute primary non-rheumatic pleurisy is a very rare condition
in children. I have seen but four cases under nine years of age — one
was eight, one seven, and one four years of age, and one only fif-
teen months old.
Its onset is practically the same as in adults. There is localized
pain, the so-called "stitch in the side," the respiration is rapid,
fortv to sixty to the minute, and shallow; the skin is dry and hot;
the cough is teasing, and, on account of the pain which it causes,
is partially suppressed by the patient. Fever is present which is
usually quite high, 102° to 105° F. The pulse is rapid, one hun-
dred and twenty to one hundred and fifty to the minute. In only
one of my cases was the pleuritic inflammation followed by effu-
sion. This was in the child fifteen months old. The fluid in this
case was sterile. So far as we could learn there was no rheumatic
association in any of the cases.
Treatment. — The treatment which proved successful in the four
cases was rest in bed. The patients were given a reduced diet of milk,
broths, and gruel. The fever was not of a very persistent character
and was readily controlled by sponge-baths (page 30). For the relief
of the pain, a flaxseed and mustard poultice, — one part of mus-
tard to nine parts of flaxseed, — applied as hot as could be borne
by the back of the nurse's hand, and changed every half hour, gave
much relief during the acute stage. After the first twenty-four
hours, however, poultices are of little value. Strapping the affected
side with strips of Z. O. plaster will give much comfort where the
SECONDARY PLEURISY 279
pain continues after the second day. Tincture of aconite in doses
of one drop every hour was given to the older children until ten
drops had been given. It produced a fairly free diaphoresis and
made the patients more comfortable. A grain of calomel in divided
doses was given early in the attack, one -tenth of a grain being
given every hour. The duration of the acute symptoms was ordinar-
ily from twelve to twenty-four hours; the entire duration of the
illness ranging from five days to one week. In the youngest child,
with effusion, absorption appeared to be stimulated by the intro-
duction of the needle and the withdrawal of a small amount of
fluid, the remainder quickly disappearing afterward. To relieve
the cough, small doses of codein, one-tenth of a grain every two
hours, were given the older children.
SECONDARY PLEURISY
Pleuritic inflammation, as a complication of disease of the lungs
or as a result of disease in other parts of the body, is of very fre-
quent occurrence in the young. Pneumonia furnishes by far the
greatest number of cases, lobar more than catarrhal or broncho-
pneumonia. Tuberculosis is possibly the next most frequent cause
of secondary pleurisy, which is almost always without effusion of
any moment. If the disease is of considerable duration, adhesions
binding the lung to the chest wall will invariably be found at au-
topsy. Secondary pleurisy may follow pericarditis. Such an occur-
rence, however, is extremely rare. It has never happened in one of
my cases.
Secondary pleurisy may be either what is known as a dry pleu-
risy or a pleurisy with effusion. When dry pleurisy exists, the
pleura has lost its normal luster and is covered early in the attack
with a shght fibrinous exudation. As the disease progresses, the
exudation may be more extensive, resulting in thick fibrous bands
and masses, a network oftentimes being formed in which is en-
closed a thick gelatinous material composed largely of pus cells.
Repeatedly at autopsy I have found the lung so thoroughly bound
to the chest wall that its removal without the aid of force was
impossible.
In pleurisy with effusion, a fluid composed either of pus or serum
will be found in the pleural cavity. I have never seen a case in which
the effusion in a pleurisy secondary to pneumonia did not contain
bacteria. The fluid upon withdrawal may appear clear, yet bac-
teriologic examination will show that it is not sterile. It may be,
and often is, the first manifestation of a purulent pleurisy or empy-
ema. In the very young, rheumatic pleurisy (page 463) is extremely
rare. I have seen but six cases in children under four years of age.
Treatment. — The treatment of dry secondary pleurisy is usually
that of the disease which it complicates. I have never known any
28o DISEASES OF THE RESPIRATORY TRACT
special medication to be of any practical value. Tonics and suppor-
tive measures generally are of service. Anything that will improve
the condition of the patient should be brought into use. A change
of residence from the city to the country for those who can afford
it, or an outdoor life in the city for those who cannot avail them-
selves of such a change is always beneficial. Counter-irritation
to the chest with mustard or iodin will often give relief to the
patient if there is pain, but otherwise it possesses no value. Occa-
sionally there is a sense of "tightness " and constriction of the
chest, which amounts to pain, and this condition mustard or iodin
will relieve. Painting the affected area with tincture of iodin
every second or third night has in a few cases afforded some relief.
The administration of iodids as an aid to absorption is of question-
able value and is very apt to disturb digestion. The application
of a mustard plaster (page 493), one-third mustard and two-thirds
flour, to the bare skin over the diseased area for ten or fifteen min-
utes, at intervals of six or eight hours, w^ll add to the comfort of
the patient. When after recovery from the pneumonia or the
empyema adhesions persist, with restricted lung action, active
exercise in the open air is to be encouraged. For younger patients
horseback-riding, the bicycle, and breathing exercises, with active
games in which they become interested and which require deep
breathing, do better than anything else. The glass tubes of James,
recommended by many, wnth which the child blows colored water
from one bulb to another, have been of no value in my hands, because
their use will not be persisted in long enough for benefit. The
apparatus is a toy. The child soon tires of it, as of any toy, and
its use will be discontinued.
PRIMARY TUBERCULOUS PLEURISY
Primary pleurisy due to tuberculous infection is exceedingly
rare in children. I have seen but one such case, and that in a child
two years of age. Three ounces of fluid were removed from the
chest; in four weeks signs of infiltration appeared in the lung;
and in eight weeks after the attack of pleurisy the child died from
general tuberculosis. The treatment is the same as for pulmonary
tuberculosis.
EMPYEMA
By empyema we understand a collection of pus in the pleural
cavity, the pus being the product of an inflammation of the pleura
which has become infected with pathogenic organisms. Bacterio-
logic examination of the pus shows the pneumococcus to be present
in pure culture in a large percentage of the cases. The strepto-
coccus and staphvlococcus, alone or in combination with the pneu-
mococcus, are seen less frequently. The tubercle bacillus is rarely
EMPYEMA 281
a factor in empyema of the young. In forty-five cases I have seen
but one in which it was present. Empyema is rarely a primary
disease. It is usually secondary to pneumonia, only very rarely
to a suppurative process in another part of the body. In all my
own cases it followed pneumonia, and if an accurate history were
obtainable this would be the record of fully 95 percent of the cases.
The development of the average case of empyema would be very
much as follows: The child had catarrhal pneumonia or broncho-
pneumonia, running the usual course as to fever, respiration, pulse,
and prostration, and after a time, from six to twelve days, an im-
provement in the symptoms was noticed, the pulse and respiration
became slower, and the child brighter. For twenty-four hours
the temperature range was lower. During the height of the pneu-
monia it was perhaps 104° or 105° F., now it ranges from 100° to
102° F., occasionally dropping to 99° F. Such a temperature con-
tinues for a few days, when it is noticed that it is lower in the morn-
ing than in the evening, although the evening temperature may
not be over 102° F., perhaps occasionally reaching 103° F. The
child coughs, the pulse is rapid, 120 to 140, the respirations accel-
erated, 40 or over. The appetite is poor. These symptoms, with
progressive emaciation, may continue for weeks if the condition is
not recognized.
The course of development of an empyema after a lobar pneu-
monia is somewhat different. The crisis occurs and the tempera-
ture falls to normal; all goes well for a few days, — four or five,
perhaps, — when a slight evening rise occurs. The temperature
is lower the next morning, but not quite normal. The followdng
evening it is higher than the preceding. Such a temperature range
is almost pathognomonic of empyema.
Empyema is often mistaken for tuberculosis, malaria, typhoid
fever, or unresolved pneumonia. An enumeration of the points
necessary for making a differential diagnosis is not within the scope
of this work. It may be said, however, that when the physician
is in doubt, the aspirating needle should always be used (Fig. 27).
If the needle is sterile — and there is no excuse for its being other-
wise— and if the skin is properly prepared, there is no danger of
infection. The skin should be prepared as follows: A thorough
scrubbing with tincture of green soap should be followed by scrub-
bing with a solution of bichlorid of mercury, i : 2000; this, in turn,
is followed by washing with alcohol, which is then applied on absor-
bent cotton and allowed to remain for at least one minute at the site
of the proposed puncture. It is well to use a large needle, so that
in case the pus is thick it will the more easily pass through it. The
child should be held in an upright position, the needle introduced
at the site of the greatest dullness. After the withdrawal of the
needle, adhesive plaster should be placed over the wound.
282
DISEASES OF THE RESPIRATORY TRACT
Treatment. — The pus being located, operation is the only means
of treatment. Aspiration of the pus should not be considered a sub-
stitute for incision. In a recent case in a young child under two years
of age an incision with local anesthesia is all that will be required.
In older children, or in a prolonged case in a young child, a resec-
tion of the rib is to be advised as furnishing a much freer drainage.
■Occasionally cases are seen among older children in which, on account
of a very severe, persisting pneumonia, it will not be safe to use
a general anesthetic. In such cases an incision may be made under
cocain — a 4 percent solution being injected into the skin at the site
of the proposed incision. Such an operation will relieve the imme-
FiG. 27. — Potain's Modification of Dieulafoy's Aspirator.
diate symptoms — the displacement of the heart and the diflficult
breathing. The resection of a rib may safely be undertaken after
a week or two, when considerable improvement will have taken place
in the general condition. As soon as the cavity is opened, two
half-inch drainage-tubes from two to four inches in length joined
with a large safety-pin are inserted. Gauze is packed around the
tubes and against the skin, and upon this the pin rests. Sterile
gauze is placed over the end of the tubes as soon as possible after their
introduction, in order to prevent a too free escape of pus. When
the pus is allowed gradually to escape, much less shock will be
experienced. Over the gauze two or three layers of absorbent
cotton are placed, and over this the bandage. The dressing should
KMPYEMA 283
be changed every day and the tubes shortened as the lung expands.
This expansion will be indicated by the resulting outward displace-
ment of the tubes. After the evacuation of the pus, the pulse usu-
ally falls to normal or nearly normal, where it remains. Occa-
sionally, however, cases are seen in which this expected result
does not follow the operation.
Illustrative Cases. — In one of my cases the operation was followed
by a free discharge of pus, but with no relief whatever to the symp-
toms. An examination of the chest revealed at the apex of the lung
a pocket of pus which had become walled off by adhesions. The
case was one of three months' duration when it came under my
care. A second operation removed about six ounces of pus, but
the child died from exhaustion about twenty-four hours after-
ward. Autopsy showed that the pleural cavity was divided into
two distinct pus sacs by a firm band of adhesions.
In another case, that of a girl of five years, on account of the re-
duced condition of the child, — the empyema following a pneumonia,
— an incision was made instead of a resection of the rib. The temper-
ature fell to normal and all the symptoms improved for a few days,
when an evening rise to 101° F. and over was noted which in two or
three days reached 103° F. There was a discharge which saturated
the dressings, although they were changed every three or four hours.
Our inability to locate an independent pus pocket, the continued
fever, and a strong odor to the discharge, suggested the proba-
bility of insufhcient drainage. In spite of the fever, the child having
gained considerably in strength, a second operation was decided
upon to enlarge the wound. She was anesthetized and two inches
of rib removed, when quantities of necrotic fibrinous material were
found in the pleural cavity. These were removed with the finger
and dressing forceps, when the temperature immediately fell to
normal and the child made a perfect recovery. Irrigation of the
cavity had been of no avail.
Ordinarily the tubes should not be removed until from four to
six weeks after the operation. They should remain in position until
a free respiratory murmur is heard all over the affected side up to
the site of operation in the chest wall. When the lung is fully
expanded, the tubes will be forced out and found in the dressings.
Irrigation of the pleural cavity is not to be advised as a routine
measure, and with sufKicient drainage it will not be necessary. The
cases which require irrigation on account of continued fever and
insufficient discharge require a resection of the rib. Should a
second operation be refused, or be inadvisable, on account of the
tender age or the general weakness of the patient or on account of
some compHcation, such as a pericarditis, a daily irrigation with
a sterile normal salt solution may be undertaken.
284 DISEASES OF THE RESPIRATORY TRACT
DOUBLE EMPYEMA
Two of the forty-five cases of empyema which I have seen were
bilateral, both pleural sacs being involved. In such cases both sides
should not be opened at the same time, on account of the danger
of collapse of the lungs. There are usually adhesions present suf-
ficiently strong to prevent this, but we have no means of knowing
this beforehand. In both of my cases, the left pleural cavity was
opened first, in order to relieve the- pressure upon the heart and
the great vessels. In one case a considerable quantity of pus was
removed from the right side by aspiration, at the time of the opera-
tion on the left side. The right side was operated upon four days
later, by which time sufficient adhesions had formed to preveni
collapse of the lungs. The patient, a boy of two years, made an
excellent recovery.
The second case was one year of age. Pus had been present
in both sides for a considerable time. The left side was opened
first. The sac on the right side was smaller than that on the left,
and was operated on by incision three days later. The child was
very much reduced by the protracted illness. In spite of the
free daily irrigation of both cavities the typical temperature per-
sisted until death, probably on account of the very extensive sup-
purating surfaces. The child died from exhaustion twelve days
after the second operation.
EMPYEMA NECESSITATIS
Spontaneous rupture of the pleural sac may occur in cases of
empyema of considerable duration which are not properly diagnosed,
or not operated upon, if diagnosed. Cases of this nature have
been reported in which the pus ruptured into the esophagus, into
the bronchi, or through the diaphragm into the peritoneal cavity.
In two of the cases seen by me spontaneous rupture occurred. In
the first, pus ruptured into the bronchi. The patient was a well-
nourished boy three years of age. The pus was sacculated over
the anterior portion of the left lung. The parents, not particularly
intelligent people, objected to the operation, and while it was under
consideration by them, two or three days after the diagnosis was
made, the pus ruptured into the bronchi and was discharged from
the mouth in large quantities during a coughing paroxysm. The
child made an uninterrupted recovery. The other case, a boy
of two years, came under observation for a soft, fluctuating swelling
the size of a small orange, on the right side immediately below
the nipple. Exploration with a hypodermic needle showed pus.
An incision was made and about three ounces of pus discharged.
When the sac was emptied it was found to communicate with the
right pleural cavity by an opening between the seventh and eighth
PULMONARY TUBERCULOSIS 285
rib. The wound was dressed and the child recovered without
further comphcations.
PULMONARY TUBERCULOSIS
Pulmonary tuberculosis in young children under the fifth year
of age rarely occurs independent of tuberculosis elsewhere. At
this early period of life the disease is usually acute and fatal. After
the fifth year, particularly after the seventh or eighth year, the
disease assumes the characteristics which mark its presence in the
adult. Even at this age it is by no means of frequent occurrence.
As with the adult, so with the child, the earlier the disease is recog-
nized and the earlier the treatment is begun, the better will be the
result. The discovery of tubercle bacilli in the sputum should
not be required, before beginning rigid therapeutic measures. Loss
in weight, cough, and the characteristic, localized, auscultation
signs, however slight, are sufficient to warrant active treatment.
Given, for example, an apex involvement in a child from eight
to ten years of age, with the advantages which will be mentioned,
and the prognosis is better than in adults with equal pulmonarv
involvement, who have equal advantages.
Treatment. — Climate. — For those who are so situated financially
as to have the advantages of an equable climate, a change of resi-
dence or sanitarium treatment should be provided. A dry climate
of equable temperature that will allow the tuberculous child to
spend the greatest number of hours in the open air is the best
climate for the patient. The climate of southern New Mexico and
Arizona is best for these cases. I have had children do well in the
Adirondacks and in Sullivan County, New York, but the severity
of the winter makes these localities less desirable.
Diet. — Equally, if not more important than climate, is the nutri-
tion of the patient. This must be raised to the highest possible stan-
dard, but there should be no overfeeding — a procedure of no value in
any disease in the young. My patients have improved most on a
high-proteid diet of milk, meat, and eggs, and a high-proteid cereal,
such as oatmeal, and the legumes, — dried peas, beans, and lentils, —
which are given in the form of a puree. I have found it advisable
not to insist that a definite amount of food shall be given in twenty-
four hours, but the mother or nurse is told that these foods, prepared
in different ways so that the child will not tire of them, are to form
a considerable part of the diet. Green vegetables, fruits, and plain
desserts are given to furnish variety and to stimulate the appetite.
When three meals a day are given, with, perhaps, a glass of milk in
the middle of the afternoon, I have been able to maintain better
nutrition than with more frequent feedings. Forced feeding in
children often defeats its own purpose by producing disgust for
or intolerance of food. The child should be fed on nutritious food,
286 DISEASES OF THE RESPIRATORY TRACT
for which an appetite must be developed ; for, inasmuch as recovery-
is dependent largely upon nutrition, the question of appetite and
food capacity is of paramount importance. Candy, sweet crackers,
and other harmful articles should not be allowed. In order to
satisfy the candy craving, a small quantity of sweet chocolate may
be given after the noonday meal. The best appetizers that we
can furnish the child are reasonable exercise, entertainment and
play that does not fatigue, and fresh air in abundance, and upon
our ability to supply these requirements depends, to a large degree,
the outcome of the case.
Tenement Cases. — The majority of the cases of pulmonary tuber-
culosis in children cannot be sent to sanitariums or to health resorts.
They must be treated in their homes. This I have done successfully
in New York city even among the tenement population. The basic
principles of management are a properly directed hfe, good food, and
fresh air. These are the weapons for fighting the enemy, regard-
less as to whether the residence is among the rich or poor, in town
or country. It is, however, among the tenement population that
we experience the greatest difficulty. It is not enough to tell these
people how the child is to be fed. The feeding as directed entails
considerable expense, and the parents may not be able to meet
it. After personal investigation, which should be made in every
case if it is demonstrated that proper nutrition or suitable clothing
are impossible, I explain the situation to some charitably inclined
person of means, and have yet to know of an instance where cloth-
ing and a small but sufficient weekly food-allowance were not
forthcoming. To the best of my knowledge the child himself has
always had the benefit of the charity, and I have investigated such
cases closely. An allowance of twenty-five cents a day for fresh meat
and milk has oftentimes furnished what was required to bring the case
to a favorable termination. The uselessness of much of our medi-
cal advice to the poor would, on slight reflection or a little investi-
gation, be apparent. The physician should not trust to chance
for results, but should act so as to make results. In addition to
the diet above outlined, the advantages of an outdoor life, and
the means by which fresh air may be obtained all the year round,
are fully explained. Any simple direction as to what may appear
to be a radical procedure is rarely carried out without a rational
explanation of its necessity. During the daytime the child is kept
outdoors. In the park or in the streets is better than in the
house. Close, tightly sealed, sleeping apartments at night, however,
will undo the good of the outdoor life during the day. The mother
is told to have the child sleep alone in the largest room of the apart-
ment, and always in a room in which the windows are opened.
This is usually possible. A sponge-bath or tub-bath is given the
child at bedtime, followed by a brisk rubbing with a towel. If
BRONCHIECTASIS 287
there is much emaciation, an oHve-oil or goose-oil inunction follows
the salt bath. Sometimes these directions arc followed implicitly;
at other times they are forgotten. It is astonishing, however, what
rapid improvement will follow, when a tuberculous child of the
tenements is given the benefit of fresh air, day and night, with
suitable food and cleanliness, even though it is in New York city.
Tonics. — Among the more fortunate classes the same treatment
is to be carried out. In these, however, we see fewer cases. The
usefulness of drugs depends to a large degree upon an increase of
food capacity which their use may cause. Either of the prescrip-
tions written below may be alternated with cod-liver oil and malt,
each being given for five days. For a child from seven to tw^elve
years of age, the following are useful restoratives and appetizers:
I^. Ferri et quininge citratis gr. xxiv
Vini xerici oiv
M. Sig. — One teaspoonful in water three times a day after meals.
I^. Tincturae nucis vomicae gtt. Ixiv
Extracti ferri pomati gr. vj
Ouininae bisulphatis 5j
M. ft. capsulae No. xxx.
Sig. — One after each meal.
If night-sweats are present, from o^^^ to y^^o^ grain of atropin
given at bedtime will often furnish relief. The dangers of infecting
others is fully explained to those in charge of the patient. Vari-
ous devices for collecting the sputum may be obtained in the shops.
A cheap and effective way is the use of a Japanese paper handker-
chief, which, when used, is at once placed in a paper bag, the bag and
its contents being burned at the close of the day.
BRONCHIECTASIS
Bronchiectasis consists of a dilatation of the bronchi, such dila-
tation being usually sacculated or cylindrical in form and always
associated with an interstitial pneumonia. In a child eighteen
months of age who died from bronchopneumonia of three months'
duration with terminal sepsis, there were several small cylindrical
dilatations. One of these with a capacity of six drams was found
in the right lung.
Treatment. — The treatment of the condition is the treatment of
interstitial pneumonia, and little can be accomplished with the use of
drugs except such as will improve the nutrition of the patient. Chil-
dren with this unfortunate pulmonary disease should take up their
permanent residence in a dry climate such as is furnished by Colorado
or New Mexico. A visit of a few months or a year is of but little
service. I have used the iodids and the bichlorid of mercury for
months without any appreciable improvement, in two of these cases
that could not be removed from town. The citrate of iron and
288 DISEASES OF THE RESPIRATORY TRACT
quinin, one grain in a dram of sherry wine, makes a good appetizer
for these cases. It may be given in one-fourth glass of water after
meals. Its use can with advantage be alternated with the syrup
of the hypophosphites (Gardner), one to three drams being given
daily in one-half glass of water after meals. Cod-liver oil may be
used with advantage for ten days out of a month. Its continued
use sometimes is contraindicated, as it is apt to interfere with
digestion.
In one of the cases above referred to, the iron was given for ten
days, hypophosphites for ten days, and the oil for ten days, when
the procedure was repeated. The patient continued to look well,
gained in weight, and remained under treatment until he took
up an occupation and passed from observation. The condition of
the lung had remained unchanged, the only active manifestation of
the disease being the expectoration of considerable non-tuberculous
pus every morning on rising.
The usual outcome of those cases which have not the advantage
of climatic influence is fatal. Death usually results from tubercu-
losis or from a septic process in some other portion of the body.
DISEASES OF THE HEART
PERICARDITIS
Pericarditis other than as a manifestation of rheumatism is
to be regarded as secondary to a diseased process in some other
portion of the body.
Treatment. — As far as treatment is concerned, cases of peri-
carditis may be divided into two groups, those of rheumatic origin
and those due to the invasion of the known pathogenic organisms. An
immense majority of the cases of dry pericarditis and of pericarditis
with effusion are of rheumatic origin. The pericarditis usually is
associated with endocarditis, or some other evidences of rheumatic
infection are present. As a manifestation of rheumatism, peri-
carditis may precede, be associated with, or follow inflammation
of the endocardium. The general and specific drug management
of pericarditis is largely the same as for endocarditis (page 291).
The ice-bag is used as in endocarditis, but bhsters are not applied.
They are of very doubtful utility and disturb the child consider-
ably, not only when they are being applied but for days after-
ward. When pericarditis occurs without marked endocardial
involvement, which is rare in the young, prolonged rest in bed is
not so essential.
Drugs. — For the excessive rapidity of the heart action which
is usually present, the tinctures of strophanthus and aconite are
of a great deal of service. For a child three years of age, one-
half drop of the tincture of aconite and one drop of the tincture
of strophanthus can be given at two-hour intervals, but not to ex-
ceed six doses should be given in twenty-four hours. After the
third year, one drop of the tincture of aconite and two drops of the
tincture of strophanthus may be given at two-hour intervals, six
doses in the twenty-four hours. For the extreme restlessness which
often exists, codein or paregoric may be given. For a child under
two years of age, paregoric is safer. It may be given in doses of
from ten to twenty drops and repeated when indicated at inter\^als
of two or three hours. Older children, between the second and sixth
years, should be given codein in doses of from one-tenth to one-
sixth grain. After the sixth year, one-fourth grain may be given,
to be repeated at three-hour intervals only, and not more than three
doses given in twenty-four hours. As soon as the diagnosis is made,
if the case is of rheumatic origin it is advisable to begin with the sali-
cylate of soda (wintergreen) or aspirin, in order to prevent an effu-
19 289
290 DISEASES OF THE HEART
sion into the pericardial sac. For those under three years, fourteen
to twenty grains of the sahcylate of soda or aspirin should be given
daily with twice the amount of the bicarbonate of soda. As the
salicylate is liable to cause some gastric disturbance, it should
never be given, when the stomach is empty, except in milk or with
some other food ; four grains of the salicylate is as much as should be
given at one time. After the third year, larger doses may be given.
At the tenth year, forty grains may be given daily in divided doses,
always in solution, observing the same precautions as to giving it
after meals. It is impossible and entirely unnecessary in this
country to give the large doses of the salicylate which are given
abroad.
In delicate children and in those in whom the salicylate is not
well tolerated, aspirin may be substituted or the salicylate may be
given by the bowel, using fifteen grains at a time, observing the
precautions of diluting it with at least four ounces of water and intro-
ducing it through a rectal tube which has been inserted at least
nine inches. The apparatus shown in Fig. 19 is a convenient
means of injecting the solution. It should not be given oftener
than twice daily and should immediately follow an irrigation of the
large intestine. In the comparatively infrequent cases which occur
as complications of the infectious diseases, the salicylate treatment
is not to be advised unless there is some suspicion of rheumatism
in the case. The other methods suggested are to be carried out,
with the hope that the disease may be controlled. It is in this
type of case that the ice-bag is particularly serviceable. In the
event of the effusion becoming so excessive as to interfere with
the heart action, producing orthopnea and cyanosis with feeble,
irregular pulse, operation on the pericardium, such as aspiration, in-
cision, and drainage, is to be considered, although in the few opera-
tive cases which I have seen I have not been impressed with its
great usefulness. On the other hand, I have seen cases, in which
there was an excessive accumulation of fluid, recover under less
radical measures. When it becomes evident that pus is present
in the sac, incision and drainage may be attempted, as the case
will surely be fatal if the usual methods are pursued.
ACUTE ENDOCARDITIS
Endocarditis is seen more frequently between the ages of three
and ten years than at any other period of childhood. In probably
95 percent of the cases it is of rheumatic origin. It may occur as
a complication of diphtheria, scarlet fever, or any other of the in-
fectious diseases. In two of my cases it was associated with a severe
grippe infection. When due to rheumatism, there may be other
manifestations of the disease, or the endocarditis may be the only
active evidence of rheumatism. The patient, on close questioning
ACUTE ENDOCARDITIS 29!
as to his personal history, will usually give evidence of a rheu-
matic tendency in previous attacks of rheumatism, frequent anginas,
tonsillitis, chorea, or growing pains, or there may be a family history
of rheumatism.
Treatment. — Rest in Bed. — Whatever the nature of the infection,
one rule — that regarding quiet and rest — must be followed in all. The
child must remain in a recumbent position in bed, the bedpan
being used to receive the discharges. The heart must be given
as httle work to do as possible. The use of the arms and the
hands should be discouraged, particularly early in the attack, as it
is at this time that the greatest damage is done to the heart.
Reaching from the bed to the floor or to the table or chairs should
be forbidden.
Diet. — The diet should be largely of fluids, administered in com-
paratively small amounts, at intervals more frequent than in
health. The bowels should move once daily. If a laxative is
necessary, a saline should be given. A Seidlitz powder or mag-
nesium citrate is usually effective. Distention of the stomach,
whether by gas or by food, causes pressure on the heart and increases
its labor. It is my custom, in these cases, to give five feedings
in twenty-four hours, and not more than eight ounces at a feeding.
Four ounces of milk with four ounces of gruel (see formula No. 2)
with zwieback or toast, is the usual means of feeding. In order to
vary the diet, a weaker gruel, No. i, flavored with an ounce or two
of chicken or mutton broth, may be given, or a gruel of the same
strength may be given plain, with sufficient salt to make it palatable.
As the case progresses, and the child improves, eggs, bread and but-
ter, stewed fruit, poultry, fish, and plain puddings may be added
to the diet. With the freer feeding, the number of meals should be
reduced.
The Ice-hag. — A screw-top ice-bag, half filled with chopped ice,
is placed over the heart and it should be our object to keep it on
continuously. Children frequently become restless and irritable
under this constant application of the ice, and in such instances it
may be left off occasionally for from one-half hour to one hour.
Drugs. — In endocarditis following diphtheria or the exanthemata,
the use of drugs is of little benefit; even the salicylates seem to
have no beneficial effect upon these patients. For the excessive
rapidity of the heart action which is sometimes noted, the tinc-
ture of strophanthus is more effective than any other drug. Two
drops may be given at intervals of from three to six hours to
children from five to ten years of age. If there is much excitability
and restlessness, codein \ grain, or eight grains of sodium bromid
may be given at sufficiently frequent intervals to control the
condition. While every case of non-rheumatic endocarditis is serious
as regards its possibilities for permanent damage, not every case, by
292 DISEASES OF THE HEART
any means, is of sufficient severity to demand other treatment than
the ice-bag, rest, and an easily digested diet. It is often the milder
cases that give us the gravest sequelae, on account of the lack of
objective symptoms. For this reason it is difficult to make parents
appreciate the gravity of the disease, and the child is given liberties
which should never be allowed.
Anti-rheumatic Treatment. — Every case of endocarditis, under my
care, which is not directly associated with one of the infectious diseases,
is considered and treated as though it were rheumatism, which, as pre-
viously mentioned, it almost invariably is. Sodium salicylate and so-
dium bicarbonate are early brought into use. For a child of from five
to ten years of age, from three to five grains of sodium salicylate are
given after each feeding, five times daily, with an equal quantity
of sodium bicarbonate. The drugs may be given in capsules or
in solution. If the sodium salicylate is not well borne by the stomach,
aspirin mav be given in equal dosage. The salicylate should be
given with occasional intermissions of a day or two, until the urgent
symptoms, such as fever, rapid heart, and dyspnea have subsided.
The dosage should then be varied, ten grains being given daily for
five days out of fifteen. A child who has once had rheumatic
endocarditis should be kept under close observation and the parents
warned as to the possibilities of a second attack.
Illustrative Cases. — In a private case in spite of anti- rheumatic
treatment, during the intervals, four distinct attacks have occurred
during the past five years. A dispensary patient at the New York
Polyclinic had his first attack when four years of age. So prominent
was his rheumatic tendency that during the next four years, regard-
less of active anti-rheumatic treatment and a careful diet in the inter-
vals, he had eight distinct attacks of endocarditis and died from the
heart involvement in his eighth year. There were other manifesta-
tions of rheumatism in his case, and on both sides the family for
several generations had been markedly rheumatic.
Recurrence. — Inasmuch as a recurrence is very probable, the
patient should, even while in apparent health, have the benefit of
a restricted diet, being allowed red meat but twice a week and
a minimum amount of sugar. During five days out of each month,
he should receive ten grains of sodium salicylate and ten grains of
sodium bicarbonate, daily. This scheme of medication should be
continued for at least two years, and much longer if the patient
shows anv rheumatic tendency, such as pains in the legs or repeated
attacks of tonsillitis. As to the length of time during which absolute
rest in bed is to be enjoined, every case must be decided for itself.
The time in bed for my primary cases is from six weeks to three
months. In one case, that of a boy who had had a very severe
second attack, walking was not allowed for six months, the patient
using a wheel-chair instead.
The rapidity of the heart's action is the best means of deciding
MALIGNANT ENDOCARDITIS. MYOCARDITIS 293
when the patient shall be allowed to walk. In a case of moderate
severity, the heart's action, which has been rapid, 140 to 160, gradu-
ally becomes less frequent. The temperature, perhaps, continued for
only a week or ten days.
Convalescence. — When the pulse-beat is reduced to 100, which is
not to be expected earlier than from the fourth to the sixth week, the
patient is allowed to sit in a reclining chair. Previous to this, while in
bed, he is gradually accustomed to an elevation of the head by the
addition of an extra pillow for an hour or more daily. The patient is
allowed greater freedom when it is found that he can be indulged in
it, and the heart kept below the 100 mark. The above scheme of
management may seem unnecessarily severe, but we must remember
the importance of the heart in the economy, and see to it that if
the patient cannot have a perfectly sound heart, it shall be damaged
as little as possible. It thus becomes a question of observing every
precaution that will tend toward the best possible outcome, no
matter how drastic such requirements may be.
MALIGNANT ENDOCARDITIS
MaHgnant or septic endocarditis is rare in children. I have
seen but three proved cases. One occurred with scarlet fever,
one with diphtheria, and one followed what had apparently been
a tonsillitis. In this there was an irregular intermittent type of
temperature with gradually increasing prostration and emaciation.
In one case the temperature frequently reached 105° F. A systolic
murmur was present in two cases, apparently from the onset; in
the other case it appeared three days before death, and until this
sign developed, a diagnosis was not made. The cases were all fatal.
I know of no treatment that is of value other than in meeting the
symptoms as they arise, with hypodermatic stimulation, suitable
nutrition, and antipyretic measures applied to the skin in the form
of cool packs with rest in the recumbent position.
MYOCARDITIS
Myocarditis of a mild degree is probably of much more frequent
occurrence than is ordinarily supposed. It may be associated with
inflammatory conditions of the endocardium or pericardium. It is
not here, however, that it necessarily occurs in its most severe
form. The myocardium is most apt to become involved as a result
of bacterial invasion of the heart muscle in cases of grave sys-
temic toxemia, particularly after scarlet fever, diphtheria, or
pneumonia.
Doubtless not a few of the cases which show marked irregularity
of the heart action, with attacks of syncope and cyanosis following or
associated with the above diseases, are due to a myocarditis. Often-
times the condition is thought to be a neuritis. Auscultation aids us
294 DISEASES OF THE HEART
very little in the diagnosis. There usually will be a weakened first
sound, but this may occur without degenerative changes in the heart
muscle. Persistent irregularity, with or without a tendency to rap-
idity, during the early convalescence after the acute disease has sub-
sided, is one of the first indications of the presence of myocarditis. It
is often most difficult to judge accurately of the heart action of a
child when he is awake, because of the excitement and the resist-
ance which the physician's presence may occasion. Cases in which
myocarditis is suspected should be examined during sleep, as to
the rapidity and regularity of the heart. The trained nurse's report
as regards matters of this nature is not always to be taken as clinical
evidence. Persistent irregularity of the pulse, as before stated, is
the earliest sign of this very grave disease, and when pronounced
and when the irregularity continues during sleep, with cerebral
complications excluded, the fact must be appreciated that the
child's life is hanging by a slender thread. There are few more
harrowing experiences than to have a child, when apparently pro-
gressing satisfactorily on the road to recovery after a serious illness,
die in an attempt to reach a toy or while assisting in putting on
his clothing.
Treatment. — Rest in Bed. — When the condition of myocarditis
follows even a mild attack of one of the infectious diseases, the invar-
iable rule of absolute heart rest, which I consider the most important
feature in the treatment, must be insisted upon. The patient,
whether in hospital or in private practice, is not allowed to sit up or
even to raise his head from the pillow ; a trained nurse is kept con-
stantly with him, so that he may be read to and thus entertained
while physical exertion is prevented. The child is permitted to use
his arms only, to play with simple light toys, all other exertion
being prohibited. Other than the recumbent position, quiet, a daily
bowel evacuation, and easily digested food, given in small quanti-
ties, little treatment is required. It is important to keep the
stomach free from distention with either gas or food. I prefer small
quantities of nourishment at frequent intervals to large quantities of
food at the usual meal-time.
Drugs. — In more severe cases with cyanosis and dyspnea a hypo-
dermic loaded with strychnin 5^0 grain and digitalis j\r) grain is
kept at the bedside constantly. In one of my cases following scar-
let fever, so urgent were the symptoms that three physicians were
engaged for several days, each being for eight hours daily at the
bedside, in addition to the two trained nurses, each of whom was
doing twelve hours' duty. My cases have all been given strychnin
with the thought of a possible associated involvement of the cardiac
ganglion. Further and obviously, certain portions of the heart
muscle remain free from the degenerative process and may be favor-
ably influenced by the strychnin. For a child one year of age ^i 7
MYOCARDITIS 295
grain may be given three times daily. From the first to the third
year, ^i^ to j^^ grain may be given four times daily. After the third
year the dose is subject to considerable variation, the amount depend-
ing upon the urgency of the case. Ordinarily from J- to y^u grain
may be given four times a day. If the case is very urgent and the
strychnin appears to improve the heart action, it may be given to
the point of producing its physiologic effects, such as fibrillary
twitching of the muscles of the face and the backs of the hands.
Nitroglvcerin should not be used. Digitalis is rarely given to young
children, as it is very apt to disturb the digestion if long continued ;
temporarily in older children, it may be used with advantage. A
child from five to ten years of age may be given from three to four
drops daily well diluted with water and preferably after meals. The
tincture of strophanthus may be of more service here than is any
other drug. It will be found particularly useful in those cases in
which there is a tendency to rapidity of the heart action. A child
one year of age may be given one drop every two hours in the twenty-
four ; from the first to the third year, from one to two drops at two-
hour intervals; from the third to the tenth year, from two to four
drops mav be given at intervals of from two to three hours. The
tendency of mvocarditis in children is toward recovery. How long
each case will require strict observation, and how long the treatment
will ultimatelv need to be continued, must be determined by each
individual case. One thing to be remembered, according to my
cases, is that the child either dies suddenly or makes a complete re-
covery, so that as to treatment it is better to err on the side of
caution.
Convalescence. — I have found it safe in a very few instances to
allow the child to sit up after six weeks. In the very severe case
above referred to, it was not safe for the patient to sit up in bed
until the end of the third month, and he was not allowed to walk
until the end of the fourth month. He was under observation for
one year, when he was discharged, and has remained well during the
two years which have since elapsed. At the present time there is no
evidence whatever of his former illness. A safe rule to follow is to
keep the patient in bed, as long as the rapidity and irregularity of
the heart exist. When the heart action in the recumbent position
is apparentlv normal, the patient mav be allowed to have his head
raised bv an additional pillow. In this way the head and shoulders
are graduallv raised day by day, carefully watching the effect upon
the heart. Progress is thus made toward sitting up in bed, under
careful supervision, until it is demonstrated that it causes no un-
favorable influence on the heart muscle. In the same way, standing
and walking are gradually begun. Following out this careful method
of heart rest and being governed solely by the heart action which
indicates the heart power, I have seen apparently hopeless cases re-
296 DISEASES OF THE HEART
cover completely. Whether fibrous changes are present which may
have a later influence, there is, of course, no means of knowing.
CHRONIC VALVULAR DISEASE OF THE HEART
The most important feature to keep in mind in connection with
valvular disease of the heart in children is the source of the disease.
The fact that in a large proportion of the cases it is due to rheumatic
endocarditis, and that, when endocarditis has once existed, it is very
liable to return, are points not to be forgotten; so that our first step
in the management of valvular defects is to discover the cause, and,
if it is found to be of rheumatic origin, it should be explained to the
parents that other attacks of endocarditis are very Hable to occur,
unless means are used for their prevention. In the absence, then,
of a history of endocarditis in association with pneumonia, diphtheria,
or scarlet fever, which in my experience has been of rare occurrence,
it is assumed that the valvular lesion is of rheumatic origin, even
though there may not be, at the time, positive evidence of rheuma-
tism elsewhere. In not a few of these children with cardiac disease
without a history of acute rheumatism, there will be a history of
tonsillitis, angina, coryza, asthmatic bronchitis, or chorea — all show-
ing recurrent tendencies. The patients will often be found to have
a rheumatic or gouty ancestry, and not infrequently they themselves
will be heavy eaters of red meat and sugars.
Treatment. — Our first step, then, in the management is so to
regulate the life as to prevent a recurrence of the heart involvement.
With this end in view, it is directed that meat be given the child but
once every second day, and that sugar be given in great modera-
tion. A tub-bath followed by a dry rub is given daily. The
bowels are not allowed to become constipated, and moderate exer-
cise is encouraged.
Drugs Advised. — For five days out of each month, the patient
is given, after meals, five grains of salicylate of soda (wintergreen)
and ten grains of bicarbonate of soda. This with the low meat and
low sugar diet is usually, but not invariably, sufficient to prevent a
recurrence. In a boy who has been under my care for several years,
and who has had three distinct attacks of endocarditis, I am obUged
to give the above treatment for five days with but ten days' inter-
mission. This has been continued for eighteen months, during which
time the heart has not been affected. During the past year there has
been no tonsillitis, while previously he had had severe attacks every
month or two. Both sides of the family are markedly rheumatic.
Drugs Used with Caution. — The further management of valv-
ular disease depends to a certain degree upon the location and
nature of the lesion. Right here I would sound a note of warn-
ing: Because a child has a cardiac lesion he does not neces-
sarily require digitalis. Not a Httle harm is done, in the treat-
CHRONIC VALVULAR DISEASE OF THE HEART 297
merit of diseases in children, by giving powerful drugs when they
are not indicated. Too often in heart disease the physician feels
his duty done when he gives digitahs. Many times 1 have seen
children who, because of some cardiac lesion, were taking digitalis
and strychnin, while at the same time they were suffering from
constipation, recurrent respiratory disorders, and persistent indi-
gestion due to dietetic errors, all of which had escaped the attention
of the physician.
Prognosis. — Under proper management, if begun early, the prog-
nosis in valvular disease in children is good. The heart nutrition and
compensation in children are usually most satisfactory. I have several
now under my care, in whom grave cardiac disease exists, without any
disturbance of any nature whatever which is evident to those who
come in contact with the children. In neglected cases the outlook
is bad. This is due, first, to the tendency of the endocarditis toward
recurrence; and, second, to our neglect to control the activities of the
child. The prognosis is better when the insufficiency involves the
mitral valves alone. In such cases the activities need be but little
curtailed; in fact, the patient is encouraged to indulge in outdoor
exercise, but competition in games requiring unusual exertion, tests
of speed or endurance of any nature, such as running and racing, is
forbidden. When the patient is old enough, swimming, the bicycle,
horseback-riding, and golf are advised. In boys, when the tobacco
and alcohol age arrives they must be told the dangers attending the
use of either and both must be forbidden. Girls with mitral insuffi-
ciency must be warned against excessive dancing, rope-jumping,
tight lacing, and indiscriminate eating. With both, rational exercise
is beneficial.
When the aortic valves are involved either in insufficiency or
stenosis, or when there is a considerable degree of mitral stenosis,
the child's activities should be considerably limited. Under these
conditions, with a view to the future, regardless of the existing satis-
factory compensation, I forbid the bicycle, swimming, dancing,
baseball, or any sport or game which may call for much physical effort.
The nature of the disease should be fully explained to the parent and
to the patient, when he is old enough to understand it, so as to secure
his hearty cooperation, not only as related to his activities, which,
of course, is important, but parents should be told particularly
that a tonsillitis or an angina is a danger-signal, and that the sali-
cylates are to be brought into use at once, even before the physician
is summoned. A diet of plain nutritious food, with nothing between
meals, is a very important feature in the treatment of heart disease
in children. Ordinarily it is not well to talk over the child's ailments
with him or in his presence ; in cardiac disease, however, I explain to
him as clearly as possible the nature of the illness, and insist that cer-
tain measures, particularly such as relate to restriction of activity,
shall be carried out indefinitelv. I find in this way that better co-
298 DISEASES OF THE HEART
operation on the part of the patient is secured than if he were simply
given a hst of dogmatic "don'ts." It is my custom, further, in
those who show aortic involvement or mitral stenosis, to advise what
is known as "heart rest." Every day after the midday meal, with
clothing off or loosened, the child is made to rest in a recumbent
position for at least one hour. During this time he may sleep or
read, as best suits his individual taste.
Medication. — As most of the cases of valvular disease in children
are of rheumatic origin, it will be found that the majority of the
patients are suffering from anemia, usually in mild degree. All the
benefits of nutrition, fresh air, and regularity in living referred to
under Tardy Malnutrition (page 158) should be afforded these
children. Iron alone or with arsenic is of some value here when
given with a suitable diet. A method often followed is to give, for
five days, the salicylate and bicarbonate of soda already referred to;
for fifteen days iron and arsenic, with the remaining ten days of
each month free from medication, unless cod-liver oil is well borne,
in which case it is usually given in combination with the extract
of malt. Should the patient be of an age when a capsule can be
swallowed, the following is given:
I^. Liquoris potassii arsenitis gtt. xc
Extract! ferri pomati Rr. x
Quininae bisulphatis 3 j
M. ft. capsulae No. xxx.
Sig. — Take one after each meal.
If the iron produces constipation, from one-third to one-half
grain of the extract of cascara may be added to each capsule.
Heart Stimulants. — Aside from such tonic medication, as far as
concerns the heart per se, drugs should not be given unless com-
pensation fails. This may take place temporarily, regardless of the
nature of the lesion, after some forbidden exercise, or during an
acute illness sufficient to produce prostration, and permanently, in
those cases which for any reason do badly. In the event of defec-
tive compensation and dilatation, the child should be kept in bed
until the normal heart action is restored, or until it is demonstrated
that the aid of heart stimulants is required. In these cases, particu-
larly in those of the latter type when there is a rapid, irregular pulse,
difficult breathing on excitement, and dropsy, the time-honored
remedy, digitalis, is to be brought into use. In children I prefer to
use the tincture. For a child from five to ten years old, from three
to five drops may be given after meals, three or four times daily.
The drug, because of its well-known irritant effects upon the stomach,
should be given considerably diluted. Its beneficial effects will be
noticed first in the relief of the dyspnea, the pulse becoming regular
and of increasing volume, and later in the increased secretion of
the kidneys and the disappearance of the edema. The amount of
digitalis given should be reduced as soon as the condition of the
CONGENITAL HEART DISEASE — ABUSE OF HEART STIMULANTS 299
patient will allow, but it should be continued for a considerable time
after he is up and about. The only contraindication to the use of
digitalis in children is its effect upon the stomach. This is often so
unfavorable that it causes a loss of appetite, in which case its ad-
ministration should be discontinued. In this event the tincture of
strophanthus, which is referred to repeatedly in this work, as a heart
stimulant, may be substituted in the same doses. In case a cardiac
stimulant is necessary for a considerable time or permanently, I
have had satisfactory results by alternating the digitalis with the
strophanthus, giving each for five days. The child, however, who
requires constant cardiac stimulation promises but little for the
future, and few of my cases have survived the eighteenth year.
CONGENITAL HEART DISEASE
The majority of the cases of congenital heart defects which have
come under my observation have died before the second year, usually
from some intercurrent disease. Patients who pass this period of
life rarely reach the sixth year. When the child becomes active in
physical exercise, such as in climbing stairs and in play, dilatation of
the right heart results. In two of my cases presenting such a
course death took place suddenly in an attack of orthopnea and
cyanosis. It may, however, be delayed until the child develops one of
the infectious diseases, such as measles or scarlet fever or diphtheria.
But little is to be said as to treatment. During the first year or two
no treatment is necessary. Later, if the child survives, rest, an
easily digested diet, morphin or other sedatives, with cardiac stimu-
lation hypodermically, may give symptomatic relief.
ABUSE OF HEART STIMULANTS ■
Probably the heart stimulants, such as alcohol, strvchnin, digi-
talis, and strophanthus, are given unadvisedly with greater fre-
quency to children than is any other form of medication. If given
needlessly, they are harmful indirectly, in that when the time for their
use really arrives, the system having become accustomed to their
action, less benefit is derived from them. All forms of cardiac
stimulants are of temporary value only. In some patients the stimu-
lant effect of drugs will be exhausted quicker than in others. The
common practice of giving heart stimulants, simply because a child
has pneumonia, typhoid fever, or diphtheria, is a very bad one. For
giving these drugs to the best advantage, there should be one special
indication and only one — the evidence of heart weakness. A very
rapid heart, above 150 beats to a minute in a sleeping child, may
require help, for otherwise it may become exhausted because of the
rapidity of its action. Pronounced weakness of the first sound and
the accentuation of the second sound call for stimulation. When
the heart action is irregular or intermittent, and when cyanosis de-
velops, heart stimulants are called for.
CONTAGIOUS DISEASES
CARE TO BE EXERCISED BY THE PHYSICIAN IN VISITING
CONTAGIOUS DISEASES
As a rule, physicians in attendance upon contagious diseases are
grossly negligent as to the use of proper precautions against the
possibility of themselves becoming mediums of infection. The phy-
sician who, without washing his hands, makes a practice of going
from a child ill with diphtheria or scarlet fever to patients otherwise
afflicted, is an element of great danger in any community. While
properly caring for a patient, close contact is necessary, particularly
in the treatment of throat and nose cases. Not only his hands, but
his clothing as well, may become infected. Therefore, before enter-
ing the room in which there is a contagious disease the physician
should remove his coat and his cuffs, if detachable, and turn up to
the elbows the sleeves of his shirt. If a clean gown is not available,
an ordinary clean bed-sheet will answer, this being so adjusted as to
protect the clothing, and held in position by two or three safety-pins.
My custom, when attending contagious diseases, is to keep in an ad-
joining room or closet a gown which I wear while in the sick-room.
After leaving the patient the physician should thoroughly wash
his hands with hot water and soap, outside the sick-room if possible.
An excuse may be offered for not wearing the gown, but there is none
for not removing the coat and cuffs, nor for the failure to use the
sheet, as suggested ; and none for the failure thoroughly to wash the
hands after leaving the patient.
QUARANTINE
The isolation of those ill with contagious diseases is an absolute
necessity for the protection of others. While it is advisable in cases
of scarlet fever to remove from the house children who have not had
the disease, and, in the event of diphtheria, all children, regardless of
previous attacks, such removal is often impossible. It then becomes
our duty to establish such a quarantine as will be effective in pre-
venting the transmission of the disease. In order to do this, the
child and the attendant must not come in contact with other mem-
bers of the family, whether children or adults. If the residence is a
citv or a country house, one or two rooms on the top floor are selected
for the patient, the room from which he was removed being carefully
cleaned and disinfected. If the family occupy an apartment, an
effective isolation is more difficult, but is by no means impossible.
300
QUARANTINE 30I
In such circumstances the room or rooms must be as remote as pos-
sible from the other hving-rooms. The room in which the child is
placed is prepared for the patient according to the instructions laid
down on page 43. Not only should the attendant not come in direct
contact with other members of the family, but there must be no in-
direct contact through dishes, feeding utensils, clothing, or bed-linen.
The dishes, knives, forks, and spoons should be placed in boiling
water and in this way sent to the kitchen. The clothing, towels, and
bed-linen should be placed either in boiling water or in a carbolic
solution — one ounce to two gallons of water — before sending them
to the laundry. Upon their arrival at the laundry they should be
boiled at once. A chair outside the door of the sick-room may be
used as a receptacle for the various necessities for the patient, which
are to be removed only when the person who brought them is at a
safe distance.
Two isolating rooms are better than one, and if there can be a
connecting bath-room, it is much more agreeable to the occupants.
If two rooms are devoted to the patient, one is used for day and
the other for night occupancy, the unoccupied room being freely
ventilated after the removal of the child. Observing the above pre-
cautions until the child is well, I have repeatedly carried through
to successful convalescence cases of diphtheria and scarlet fever
while other unprotected children have remained in the household
during the entire illness without taking the disease.
An incident which well demonstrates the value of proper quaran-
tine occurred at the New York Infant Asylum, Mt. Vernon, New
York, during my service as interne in that institution. The institu-
tion was built on the cottage plan, two wards in a cottage. A colored
child, an occupant of one of the upper wards, was discovered to be
ill with scarlet fever. There was an extensive rash, considerable
swelUng of the cervical glands, and the whole aspect of the case was
that of scarlet fever at its height. Through the negligence of an
orderly, the child had probably been ill two or three days before our
attention was called to him; as a consequence, thirty other children
of the ward had been exposed. In order to prevent the spread of
the disease to the other four hundred children, it was decided to
quarantine the ward with its children and the four attendants.
This was done. Twenty-six children and two women attendants
developed the disease. The quarantine, on the plan above sug-
gested, was continued for ten weeks. The thirty or more children
on the ground floor of the cottage remained there as before, but
no other case developed in the institution. In order to prevent the
spread of the contagion, there was no personal contact with those
outside of the ward, except with the physician who visited them
daily, but who always went properly protected (page 300). All
clothing and bed-linen were boiled before leaving the ward. The
302 CONTAGIOUS DISEASES
dishes and feeding utensils likewise were boiled before being sent to
the general kitchen.
If such isolation is possible in an institution among the careless
and more or less ignorant, it certainly should be equally effective
among the intelligent, who are most interested in preventing the
spread of disease.
When the quarantine is raised the child should receive a bath of
bichlorid of mercury i : 3000. If the hair is cut short and sham-
pooed with green soap, followed by the bichlorid, the disinfection is
more complete.
DIPHTHERIA
Diphtheria is an infectious, contagious disease due to the Klebs-
Loeffler bacillus. Its first manifestation is inflammation, usually of a
mucous surface, with the production of a pseudo-membrane. Any
of the mucous surfaces may be involved. Thus, under my own ob-
servation, the process has involved the nasal cavities, the lips, the
mouth, tonsils, pharynx, larynx, trachea, and bronchi. The esopha-
gus was the seat of the pseudo-membrane in one case and the con-
junctiva in several. The rectum or the vagina may also be the seat
of the disease. Constitutional and other symptoms fairly character-
istic rapidlv follow the local manifestation. There is always some
fever, but the temperature is usually low. Swelling of the glands
at the angle of the jaw is an early and important sign if the throat is
involved. The breath in many patients with diphtheria has a pecu-
liarly offensive odor which occurs in no other disease. By far the
most frequent sites of the local manifestations are the tonsils, the
fauces, and the larynx, the nasal cavities being more rarely involved.
It is not within the province of this book to go into details as regards
differential diagnosis or description of the various phases of the dis-
ease. They can be found in any text-book on children's diseases.
What is particularly necessary, in the light of modern treatment, is
that the physician familiarize himself with the clinical picture of the
disease in its various phases, so as to be able to recognize it regardless
of where or how it appears.
Antitoxin. — Owing to our increased knowledge of the etiology
of diphtheria and since the advent of the specific remedy, anti-
toxin, the disease has lost much of its former terror. It is still,
however, a considerable factor in the death-rate of all large cities.
This is due to two causes: first, to parents who fail to appre-
ciate the possible dangers that may arise from a sore throat and
who neglect to call a physician early in the illness; second, to
physicians who do not believe in diphtheria antitoxin, to those who
timidly use it in small doses late in the disease, or to those who wait
for positive clinical signs or a report of a culture before using it.
Equally as necessary as is the realization of the value of antitoxin.
DIPHTHERIA 303
is the knowledge as to how and when to use it and when to repeat it.
In many cases at the beginning of the disease, when the tonsils alone
are involved, it is impossible without the aid of the laboratory to
differentiate diphtheria from tonsillitis. I have seen case after case
in the pre-antitoxin period in which two or three days were required
to make a positive cUnical diagnosis. In towns in which a bacterio-
logic examination is possible it is in some instances safe to wait for a
report from such an examination. When in doubt, a safer rule to
follow, in those cases in which there is pseudo-membrane on the
tonsils, is to give antitoxin at once. If the case proves to be a simple
tonsillitis no harm will follow. I have given full doses of antitoxin
to patients in whom we afterward learned there was no diphtheria,
without any unfavorable results.
Illustrative Case. — During the past winter (1906-1907) I was
called to see a little girl six years old with a gray membranous patch on
the left tonsil, the size of a thumb-nail. There was a temperature of
101° F. The child was complaining of feeling tired and seemed
wretched generally. There was considerable difficulty in swallowing.
I gave at once 3000 units of antitoxin and sent to a private labora-
tory a culture from the throat. The report reached me the next
morning that the Klebs-Loeffler bacillus was absent. On visiting
the case at this time I found that the membrane had extended,
the right tonsil being covered. I repeated the antitoxin, giving
3000 units more, and took another culture. This was sent to another
private laboratory. Again the report was negative for the Klebs-
Loeffler bacillus, but the culture showed a pure growth of the strep-
tococcus. The following morning the throat began to clear, and in
two days was normal. Clinically this case was diphtheria. There
was no scarlatina, but there was some swelling of the glands at the
angle of the jaw. The child showed no symptoms whatever to indi-
cate that antitoxin had been given.
Necessity for Promptness in the Use of Antitoxin. — When there
is diphtheria and we wait for positive clinical signs or for the report
of a culture, even though but for ten or twelve hours, most valuable
time is lost, and it is this delay that is responsible for many deaths.
If there is one thing, in addition to its great usefulness, that we have
learned as to the administration of antitoxin, it is the necessity of
giving it at the earliest possible moment in the disease and of giving
it in full doses.
Dosage. — After a large experience in the use of antitoxin I am
convinced that it is often given in too small initial doses even by many
famihar with its use. In April, 1904, I commenced to use larger
doses, rarely giving less than 5000 units at the first injection. When
there is membrane on the uvula, the pillars of the fauces, or the pos-
terior pharyngeal wall, or in the nose, we should never wait for the
report of a culture, but a full dose of antitoxin should be given at
304 CONTAGIOUS DISEASES
once. The antitoxin is to be repeated eight or twelve hours later if
there is an extension of the membrane or if there is no change in its
appearance. If the throat shows a tendency toward improvement,
if there is a curHng up and loosening of the membrane at the edges, or
if it has taken on the granular appearance peculiar to diphtheritic
membrane after a full dose of antitoxin, it may be safe to wait twelve
hours longer, twenty-four hours in all, before deciding whether a
repetition of the original dose or a smaller one is required. A dimi-
nution in the nasal discharge in the nasal cases, a lessening of the
breath fetor, a reduction in the glandular swelling, and a fall in the
temperature — all are indications of improvement, but the physician
should not rest there ; the constitutional improvement , the clearing-
up process, must be rapid and complete, and when the case shows no
sign of improvement, more antitoxin should be given.
A child ill with diphtheria must be looked upon as a child poisoned ;
antitoxin is the antidote, and every case must receive enough of the
antidote to neutralize the poison. Whether this will be supplied,
depends upon the recentness of the infection when seen by the physi-
cian and upon his ability to apply the remedy. In a recent, very
severe case, in a girl eight years of age, 16,000 units were required be-
fore the disease yielded. The first injection was given on the second
day of the disease. In a laryngeal case in a boy five years of age,
9000 units were given in nine hours.
Laryngeal Diphtheria. — If, during the course of an attack of diph-
theria or in a case which may have been diagnosed as tonsillitis, the
voice becomes hoarse and croupy, it is an almost infallible sign that
the process has extended to the larynx, and 7000 units of antitoxin
should be given without delay. If, after waiting eight hours, there is
no improvement in the laryngeal symptoms, or if they have increased
in severity, 5000 more units should be given. Laryngeal cases re-
quire larger and more frequently repeated doses than do those in
which the fauces alone are involved. Cases of laryngeal diphtheria
without .previous throat involvement tax our judgment most se-
verely.
Differential Diagnosis. — It is by no means an easy matter to
dififerentiate the croup due to an acute catarrhal laryngitis from that
due to membranous laryngitis. The following points have aided
me in many instances in forming a right conclusion :
Diphtheritic Croup. Catarrhal Crocp.
Gradual onset. Obstruction intermittent with gradu-
Obstruction persistent. ally increasing severity.
Obstruction both to inspiration and Sudden onset.
expiration. Obstruction to inspiration, only.
Little or no response to emesis or in- Response to emesis and inhalations and
halations. to sedatives.
No response to sedatives.
The mode of onset is, of course, not to be relied upon absolutely
DIPHTHERIA
305
in differentiation. Occasionally the onset of catarrhal laryngitis may
be gradual while that of diphtheria is sudden. In the consideration
of a great many cases, however, the points of differentiation are of
sufficient value to warrant the attention which has been given them.
A safe rule to follow, in view of the urgent demand for early injec-
tions of antitoxin, is the same as in other forms of diphtheria, i. e.,
when in doubt, inject from 5000 to 7000 units. From the gradual
cessation of the laryngeal symptoms it is fairly safe to assume that
the child is doing well, although the breathing may not be entirely
free for forty-eight or seventy-two hours after the first injection. In
Date
6 7 8 9 10 11 1^ 13 14 15 16
Date
Hour
M.N,
M.N.
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M.N.
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lOA?
ro3°
102."
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100
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28.— Ch.\rt Showing the Effect of Antitoxin upon the Temper.^ture in
L.\RYNGE.\L DiPHTHERl.A.
cases which require intubation, 7000 to 10,000 units should be given
for the first injection and repeated the following day. According to
my observation, intubation cases require 10,000 to 15,000 units even
when antitoxin is used early, by which we understand on the second
or third day of the disease. If this amount or more must ultimately
be given, it is advisable to give it early in the disease. The earlier
the injection, the less frequent will be the necessity for its repetition.
Illustrative Case. — The chart presented in Fig. 28 well show^s the
effect of antitoxin upon the disease as represented by the tempera-
ture. The case was one of a girl eight years of age, who when I first
saw her had been ill for two days with sore throat. At the time the
3o6 CONTAGIOUS DISEASES
uvula, the pillars of the fauces, the tonsils, the soft palate, the post-
pharyngeal wall, and the nose were involved. Three thousand units
were given at once. In a similar case now I would give from 5000
to 7000 units. An improvement in the physical condition of the
child and in the local process kept pace with the temperature, both
being favorably influenced by the treatment, but it required 9000
units of the antitoxin to counteract the effect of the diphtheritic
poison.
Antitoxin in Non-operative Cases. — Seventy-one non-operative
cases of diphtheria have been treated by me with antitoxin with
doses varying from 1000 to 16,000 units, the former being given in
one case only. Among these cases one was fatal — my first and
only fatal non-operative case. The patient was given 1000 units
on the fourth day of the illness. He died on the eighth day. It is
hardly fair to include this case in the antitoxin group, as at that time
we did not know how to use antitoxin and therefore w^ere more or less
timid, and the serum was not up to its present high order of efficiency.
An early and full dosage explains the above most satisfactory results.
Nineteen operative intubation cases were treated with antitoxin, and
of these sixteen recovered. One of the fatal cases died on the second
day of the illness from a complicating lobar pneumonia. Another
was seen in consultation on the fifth day, intubated, and given 3000
units at once. The child was septic at the time and died in twelve
hours. The remaining case, also seen in consultation, was intubated
and received 3000 units on the fifth day. The antitoxin was re-
peated twice at twelve-hour intervals. The child died of heart failure
forty-eight hours after the first injection. We now know that these
children should have received at least 5000, or better 10,000, units at
the first injection and the dose repeated at eight -hour intervals.
In fourteen non-operative cases in which the injection was given
on the first day of the illness it was necessary in but one case to re-
peat the antitoxin on the following day. In all of these cases the
throats were clear in from thirty-six to seventy-two hours after the
first injection. Among twenty-three non-operative cases injected
the second day, seven required a second injection on the third day,
and in three of these a third injection was given on the following day.
Among seven third-day-injection cases, two required three injections
and two received two injections.
Late Injections. — Antitoxin should always be given in diph-
theria no matter how late in the disease the case may first be seen.
In one case first seen by me on the sixth day, 11,000 units were
given in three injections at eight-hour intervals. The child recov-
ered. In another case, already referred to — the one of laryngeal
diphtheria in a boy five years of age, who was first seen on the fifth
day — 11,000 units were given in nine hours with prompt recovery.
I have used the antitoxin as late as the eighth day of the disease
DIPHTHERIA 307
with benefit and recovery, and it is my belief that the patient
would not have recovered without it. In order to be signally
effective, the serum should be given not later than the third day.
The later it is given, the greater the amount required, and the greater
the need of repeating the injection. Considerable discredit has been
thrown upon the antitoxin treatment by the timid and by those not
familiar with its use. We frequently hear of cases of diphtheria
dying after the administration of antitoxin, the patient having re-
ceived but 2000 or 3000 units, and that amount perhaps late in the
disease. It would be as irrational to claim that quinin is of no
value in malaria, because three or four grains daily make no im-
pression on the disease, as it is to claim that antitoxin is of no value
in diphtheria, because two or three thousand units are given with-
out beneficial results, even when administered early in the disease.
Blood Changes Due to Antitoxin. — It has been claimed that
antitoxin produces deleterious changes in the blood, affecting par-
ticularly the red blood-corpuscles. Bearing on this statement we
quote from Ewing's "Pathology of the Blood": "The red cells
in the blood show no distinct or uniform effects from the use of
antitoxin, although in some subjects there is a moderate reduction
lasting a few hours. On the other hand, the use of antitoxin, by
limiting the progress of the infection, tends to prevent further
disintegration of the blood-cells. Within one-half hour after the in-
jection of antitoxin the leukocytes, particularly the polynuclear
form, if previously abundant, show a marked dissemination, and
in most cases, although the leukocytosis returns after twenty-
four hours, it seldom reaches its previous grade." Ewing noted a
reduction of leukocytes after antitoxin in all but two fatal cases,
while Schlesinger found it in all of his examinations. A marked
leukocytosis is usually present in diphtheria, various writers estimat-
ing the number in a cubic millimeter at from 25,000 in an average
case, to 50,000 in a severe one.
Urticaria. — In 20 percent of my cases urticaria followed the use
of antitoxin. The most severe urticaria occurring under my ob-
servation followed an injection of 3000 units. The earliest ap-
pearance of the eruption was on the fifth day following the injection ;
its latest appearance, on the twenty-first day. The urticaria ap-
parently differs in no respect from that due to other causes and the
treatment should be the same. Among local applications, a i
percent solution of carboHc acid, or a lead and opium wash, relieves
the itching better than docs any other measure. For internal ad-
ministration, salicylate of soda answers better than any other form
of medication. For a child five years old three grains well diluted
may be given every two hours until five doses have been taken daily,
the treatment being thus repeated every day until the rash disappears.
When a member of a family becomes ill with diphtheria the sug-
3o8 . CONTAGIOUS DISEASES
gestions in Quarantines (page 300) should be carefully followed
out.
Immunization. — In every case of diphtheria other children of the
family should be immunized. Never less than 1000 units should
be given for this purpose, regardless of the age of the child. Cul-
tures should be taken from the throats of children and adults alike.
If the Klebs-Loeffler bacillus is found, the case must be isolated
and treated as diphtheria, so far as quarantine is concerned. Two
of my cases developed diphtheria after immunizing doses of anti-
toxin. A child nine months of age was given 3000 units and de-
veloped diphtheria four days afterward. The patient recovered
after a second injection of 3000 units. A boy four years of age
was given 1000 units for immunization. He developed diphtheria
in thirty-six hours, which was controlled by the injection of 3000
units. The throat was clear in forty-eight hours after the second
injection.
Choice of Antitoxin. — The author has used successfully the
antitoxin prepared by Parke, Davis & Co., by H. K. Mulford &
Company, and by the Health Department, New York city.
-^^
Fig. 29.— " Record " Antitoxin Syringe.
Means of Injection. — There are several antitoxin syringes on
the market, any one of which may be used if it will admit of re-
peated boiling, for in every instance the syringe should be boiled
before using. The "Record" antitoxin syringe^ (I'ig- 29) satisfac-
torily fulfils these requirements. Some of the private producers of
antitoxin furnish it in glass bulbs with appliances for injecting it
subcutaneously. The advantage possessed by this combination is
its convenience and its safety, for as the instrument has to be used
but once, the danger of infection by means of a syringe which is
used repeatedly is thus avoided.
Site for Injection. — The skin over the abdomen between the um-
bilicus and the anterior spine of the ilium is doubtless the most
convenient site for the injection. The skin is very loosely attached
at this point and the serum passes freely under it, requiring very
little force and producing no laceration of the tissues, nor does the
soreness of the parts interfere with the child's customary position
in bed. If the buttocks, favorite sites for the injection with
'The " Record" antitoxin syringe may be obtained of James C. Dougherty,
409 West 59th St., New York.
DIPHTHERIA
309
many, are selected, the needle should be inserted well up on the
side, so as not to interfere with the child's resting on his back.
Before injecting, the skin should be thoroughly scrubbed with
green soap and washed with alcohol. Upon the withdrawal of the
needle, the skin should again be washed with alcohol and a piece of
Z, O. plaster, one inch square, appUed over the site of the injection.
With these precautions regarding cleanUness there has never been, in
my experience, a suggestion of a local infection.
Remedial Measures Other Than Antitoxin. — Among the many
remedies which have been advocated and used from time to time in
the treatment of diphtheria, practically none remains in use at the
present time. During the pre-antitoxin period I had abundant
opportunity, in 103 cases at the New York Infant Asylum, to
test the value of drugs, inhalations, vaporizing treatment, local
applications, gargles, and sprays. In an article relating to this epi-
demic of diphtheria which was written by me several years ago,
is the following statement: "The death-rate in the institution
from diphtheria was large. About 60 percent mortality. In so far
as the methods of treatment were concerned all were equally value-
less. The mild and some moderately severe cases recovered under
good general management. The severe cases died regardless of treat-
ment." In other words, there was no method or scheme of treatment
used at that time that was of any signal value. Happily, at the pres-
ent time, all the old methods are forgotten. We do not need them.
Antitoxin is a specific. The use of sprays and gargles and applica-
tions are of value as a means of cleanliness only. For this purpose
the throat irrigation (page 245) answers better than any other. For-
cible irrigation of the nose should not be employed. In such cases
the danger of forcing infected material into the eustachian tube with
resulting secondary otitis is a real one. In small children, if the
breathing is interfered with because of membrane or tenacious
secretions in the nose, a few drops of liquid albolene instilled every
hour will give as much relief as can be furnished by any other local
measure.
Sick-room Regime. — In the management of diphtheria the same
sick-room regime should be followed out as in other serious diseases.
The temperature of the room should never be above 70° F. and at all
seasons of the vear there should always be a free communication with
the outer air by means of an open window. The child should wear
its ordinary night-clothes and the bed-clothes should be of the same
weight as those used in health. The nutrition of the patient is most
important. As a rule, food is poorly taken because of the pain
caused by swallowing. Inasmuch as but a few ounces may be taken
at one time, it is well to give the nourishment in as concentrated a
form as possible. Milk should be given as the chief article of diet,
with the addition of lime-water or bicarbonate of soda. If the taste
3IO CONTAGIOUS DISEASES
of milk is disagreeable to the patient, it may be mixed with equal
parts of a thick gruel and well salted. Animal broths possess so
little nutriment that it is unwise to use them. The milk, plain or
diluted, will often best be taken if given cold or cool, even by children
under one year of age. It will usually also be taken from a spoon
or cup better than from a bottle, because of the discomfort produced
bv drawing on the nipple. When sufficient nourishment will not be
swallowed, gavage (page 134) may be brought into use, or rectal
alimentation (page 139) may aid us temporarily in maintaining nu-
trition. The temperature is rarely high enough in diphtheria to
require the use of any means for its reduction. In case of high
fever the sponge-bath (page 480) or cool pack (page 481) will answer
the requirements. When the heart action becomes weak, irregular, or
intermittent, stimulation will be necessary. For this purpose three
drugs are of signal value — strychnin, tincture of strophanthus, and
alcohol.
Intubation
To the genius of the late Dr. Joseph O'Dwyer, of New York, is
due the credit of perfecting this operation, which will forever stand
as a monument to the inestimable service which he rendered to man-
kind. The O'Dwyer intubation set (Fig. 32) furnishes us with the
Fig. 30.— Extubator.
necessary instruments for the operation. Various modifications of
the tubes, the introductor, and the retractor have been attempted
from time to time by others, but the original perfected design of
O'Dwyer has yet to be improved upon.
Intubation of the larynx may be required in a retropharyngeal
abscess, situated low on the posterior pharyngeal wall. It may be
required in edema of the larynx and in acute laryngitis. Its greatest
usefulness, however — that for which it was designed — is to relieve
the stenosis of laryngeal diphtheria. Before attempting to introduce
a tube into the larynx of the living subject the physician should
INTUBATION
311
familiarize himself with the operation on the cadaver. In no other
way can the operation safely be learned. Attempts at intubation
by the unskilled on the living subject can result only in laceration
and other gross injuries to the parts.
When to intubate is a question puzzling alike to students and to
Fig. 32.— O'Dwyer Intubation Set.
many physicians. It has been variously answered, and many at-
tempts have been made to formulate a series of cUnical manifesta-
tions the presence of which would render the operation necessary.
Thus, it has been said that it is indicated when there is a pronounced
recession of the suprasternal and infrasternal regions, and when, as a
result of stenosis, air enters the bases of the lungs but feebly or not
312
CONTAGIOUS DISEASES
at all. It may safely be said that intubation is never done too early,
but it is very apt to be done too late — not too late in a great majority
of instances to be of some service to the patient, but too late to be of
the greatest possible service. My rule regarding intubation in laryn-
geal diphtheria is to intubate when I see that the child is becoming
exhausted by his frantic struggle for breath. Diphtheria is a disease
in which every possible strength-unit must be preserved. Energy
Fig. -?:(.— Position for Inttbation.
wasted in supplying air is an unnecessary waste, since O'Dwyer has
shown us how to introduce a tube into the larynx.
Operation. — For the operation of intubation, the patient should
be wrapped from his shoulders to his feet in a sheet securely pinned
from top to bottom. The older and stronger the child, the more this
is necessary (Fig. 33). The patient is held on the lap of the nurse,
who passes her right hand around the child's body. The child's
head rests on the nurse's right shoulder, firmly held in position by
her left hand. In large, strong children it may be necessary for a
INTUBATION 313
third person to hold the child's head. The gag being introduced,
the operator, with instruments and hands disinfected, holds the in-
troductor in his right hand, locates the glottis with the forefinger of
the left, and, using it as a guide, directs the tip of the tube into the
larvnx. He must be certain that the tip is properly placed before
exerting pressure to put the tube into position. This can readily be
appreciated by one who has practised on the cadaver. When posi-
tive that the tip of the tube is engaged in the glottis, gentle pressure
will put it into position. Force should never be used, even when the
tube is started right, for the child may require a smaller tube than his
age indicates. This is rather unusual, however, as are the cases
which require larger tubes than the age calls for. When the tube is
easily coughed up, it is my custom to introduce the next larger size.
With the tube in position, the obturator is quickly removed. I
never trust to pressure on the shank of the introductor to disengage
the obturator, but keep the guiding index-finger of the left hand on
the expanded head of the tube in order to insure its remaining in
position during the extraction of the obturator.
Results of Intubation. — After the operation the child who has
previously been struggling will take a deep inspiration and cough.
One of the most welcome sounds to the operator is the sharp rattle
produced by the passage of air through the mucus which has been
forced into the tube. This tells him that the tube is in position and
that speedy relief of the stenosis may be expected. The intubated
child will usually cough vigorously for several minutes, and in so
doing may bring up a quantity of mucus and shreds of membrane.
I have often been astonished at the large pieces of membrane and
the quantity of thick mucus that can pass through the compara-
tively small lumen of the tube. In a few cases, the presence of the
tube in the larynx has caused such a persistent cough that a seda-
tive was required to control it. Small doses of bromid of soda —
four grains every half hour for two or three hours, for a child four
years of age — usually answer the purpose. The thread, looped and
knotted, which has been attached to the tube, should be long enough
to extend four or five inches beyond the lips. In case relief to the
stenosis is not immediately perceptible after the operation, or if the
breathing is made more difficult, one may be sure either that the
tube is not in position or, if in position, that it is plugged with
membrane, or that membrane may have become disengaged and is
pushed downward ahead of the tube. A tube in the esophagus,
where, in my hospital service, I have seen it placed by internes, may
exert sufficient pressure upon the posterior portion of the larynx
effectually to impede respiration.
Illustrative Cases. — Several years ago I was called to intubate a
boy two years of age who was suffering from moderate stenosis due
to diphtheria. The tube was easily introduced, but its introduc-_
314 CONTAGIOUS DISEASES
tion was followed by entire cessation of respiration. The tube
was immediately extracted by means of the attached thread and was
found to be plugged with membrane requiring considerable pressure
with a wooden toothpick to dislodge it. The stenosis was somewhat
relieved as the result of dilating the parts and a removal of a por-
tion of the membrane, but not sufficiently to furnish permanent
relief to the patient. The tube was again introduced, followed by a
complete relief of the stenosis.
When membrane is dislodged and pushed ahead of the tube it will
usually be expelled by coughing, after the extraction of the tube.
A case of this nature, following the withdrawal of the obturator,
occurred in a child six years of age, whose breathing, before difficult,
was impossible. The child struggled violently, became much ex-
cited, and with one hand free, knocked the gag from his mouth. In
my efforts to extract the tube the string broke, and while reintro-
ducing the gag in order to use the extractor, the child's struggles and
attempts at coughing dislodged both the tube and a large amount of
membrane, one piece of which, enclosing the tube, came out as a per-
fect cast of the larynx and upper trachea. The relief was immediate.
Re-intubation was not attempted nor was it necessary later. The
child had been given 5000 units of antitoxin twenty-four hours before,
which helps explain the dislodgment of the membrane.
With the introduction of antitoxin, the necessity for intubation has
become less frequent. The free use of antitoxin — 5000 to 10,000
units as an initial dose, given with the first sign of obstruction and
repeated at eight-hour intervals until two, three, or more doses are
given — will further reduce the number of cases requiring intubation,
making it a still rarer necessity. Fortunately, in laryngeal obstruc-
tion due to diphtheria, the stenosis is usually of gradually increasing
severity, so that by the early use of antitoxin many cases are relieved
before the necessity for operation arises.
SCARLET FEVER
Scarlet fever is one of the most dangerous diseases to which
children are subject, because of its marked tendency to complications.
We never know in a given case, whether mild or severe, what the
morrow may bring forth. For this reason the most scrupulous care
is absolutely necessary in the dietetic and sick-room management.
The patient must be kept in bed throughout the entire illness, of
from four to six weeks; i. e., from the onset, first manifested by sore
throat and fever, until the desquamation is completed (see Quar-
antine, page 300). We must realize at the outset the possibiHties as
to the virulence of the infection and the complications. The_^death-_
rate in scarlet fever epidemics varies from 10 to 30 percent. In
greater New York from 350 to 450 children under ten yearsbf age
die from scarlet fever or its complications every year. In order to
SCARLET FEVER 315
do our full duty to the patient, we must place him in the best pos-
sible position for successfully combating the disease.
The Sick-room. — The sick-room should be as large as it is possi-
ble for the family to supply. It is desirable that it be well lighted
by two windows which will make free ventilation possible. For the
latter purpose, the window-board (page 43) answers well. There
should always be a direct communication with the open air, except
when the child is being bathed or its clothing changed. Light and
the free circulation of fresh air are absolutely necessary for the
proper management of a severe case of scarlet fever. If possible,
two rooms should be used — ^one for the day, the other for the night.
The room which is not occupied should have the window or windows
wide open. When nephritis, endocarditis, or otitis develops, it is the
result of the scarlet fever poison or associated infection, and not be-
cause a window was left open, or a few rays of sunlight streamed into
the room.
Clothing. — The child requires no extra jacket or wraps. The
customary night-gown with the light gauze undershirt and the usual
bed-covering is all that is required.
Urine Examinations. — The urine should be examined for albumin
every day. It is my practice to have the family get a few test-tubes
and a bottle of chemically pure nitric acid. When the busy physician
has the daily specimen sent to his ofhce or carries it home himself,
it is sometimes forgotten, misplaced, or lost. During convalescence,
when the daily visit is not made, the nurse or some intelligent mem-
ber of the family can be instructed to make the test and report if
trouble is discovered. Because of a lack of these precautions,
nephritis may easily be overlooked until puffiness about the eves and
edema of the lower extremities are discovered by the attendant after
albumin had been present in the urine for several da vs.
Diet. — In the bottle-fed the food strength should be reduced one-
half during the acute febrile stage by the use of boiled water. If the
child is getting eight ounces of a milk mixture, four ounces of this mix-
ture should be given with four ounces of water. In older children,
the diet is not only considerably restricted during the acute stage,
but during the entire course of the disease. During the acute febrile
stage diluted milk, gruels, and orange-juice should constitute the
diet. For a child from two to four years of age, five ounces of milk
with five ounces of barley gruel No. 2 (see formulary, page 124) may
be given at four-hour intervals — four to five feedings in twenty-four
hours, which make an acceptable diet. Variations may be made in
the gruels used. Wheat, rice, and granum may all be brought into
use, made as suggested in the formulary and given with equal parts
of milk. It is always well, in the feeding of sick chijdren, to provide
for some variety in the food, in order that the child may not tire of it.
The juice of one-half an orange may be given twice daily, three hours
3l6 CONTAGIOUS DISEASES
after the milk and gruel feeding. For the sake of variety in the diet, I
occasionally allow a glass of whey or kumyss, or a glass of skimmed
milk containing one-half ounce of lime-water. Toasted bread, zwie-
back, or plain crackers, dry or in diluted milk, may be given occa-
sionally.
The exclusive milk diet in the management of scarlet fever, about
which we have all heard and still hear a great deal, has not been as
successful in my hands as has the foregoing. My observation has
been that the exclusive milk diet is apt to produce constipation,
intestinal indigestion, coated tongue, loss of appetite — in fact, the
child "grows stale" on the milk, which is to be our dietetic mainstay
during the weeks that are to follow. During the post-febrile period,
slight additions are made to the diet by the use of farina, hominy,
wheatena, and the lighter cereals, prepared as a porridge with a
sprinkUng of sugar and a httle milk. The child's customary diet
should not be resumed until four weeks have elapsed from the com-
mencement of the attack. If the case has been a severe one, showing
marked svstemic infection, six weeks should elapse before the full
diet is resumed.
Bowel Evacuation. — There should be one evacuation of the bowels
daily. If this does not take place, a soap-water enema should be
given. If, on account of the diet and the recumbent position, there
is a tendency to constipation, a glass of malted milk — six teaspoon-
fuls of the malted milk to eight ounces of water — as a part of the
evening meal will be of service in relieving the condition. The ad-
dition of one teaspoonful of cocoa will be grateful where the taste of
malted milk is objectionable.
Laxatives. — As a laxative during the acute febrile stage, citrate
of magnesia is very satisfactory. As a rule, children like it. It may
be given in doses of from two to four ounces, to children from two to
five years of age. In case it is not well taken, from one to two tea-
spoonfuls of the aromatic cascara may be given.
Specific Medication. — There is no specific medical treatment for
scarlet fever. Many of my cases have passed through the entire ill-
ness without the use of any other measures than those suggested
above.
Serum Treatment. — The value of the serum treatment has been
by no means demonstrated, and its use is not advised. The pre-
paration of serum and its use before we know the nature of the scarlet
fever poison is, to say the least, premature. The only use of serum
therapy, so far as we know at the present time, regardless of the kind
employed, is to assist the organism in battling with the disease.
Nursing. — As the course of scarlet fever is distinctly cyclic in
character, much can be done in the most severe cases to prevent
complications, and to relieve the patient of his temporary burden.
Since one of the most important offices we have to perform is to
SCARLET FEVER
317
keep the vital force at the highest possible point, we must do every-
thing in our power to preserve the natural resistance of the patient,
and this we have done in no small degree when we have so arranged
clothing, diet, fresh air, bowel evacuation, sleep, and quiet, as to
insure the child's comfort and well-being. The amount of vitahty
wasted by an uncomfortable, restless child in twenty-four hours may
turn the case from a successful to a fatal issue.
I fully believe in "spoiling" a sick child. If a child is more at
ease with the mother, the mother's place is with the child. If the
mother's presence disturbs the child, as it does in some instances,
she should be kept in the background. If it is apparent that the nurse
selected is not to the child's liking, or not adapted to the case, another
should be secured. I have been obHged repeatedly to take my best
nurses from children gravely ill, because the patients were irritable
and unhappy in their presence.
Quiet. — Quiet is most necessary. One person in the sick-room
with a child very ill is all that should be allowed. A second person is
of no service, and if admitted, good air is vitiated; moreover, it is not
to be expected that two persons of the "female persuasion" in the same
room will not talk!
Indications of Severity. — The physician who has seen a few cases
of scarlet fever can usually judge within the first three days as to the
severity of the infection. It is indicated by the character of the rash,
the height of the temperature, and to a lesser degree by the severity
of the angina. A case which, on the second or third day of the rash,
shows a temperature range from 101° to 103° F. means that we have
not a very severe infection and that the case probably will be mild.
Control of Fever. — A case in which the fever rises suddenly to
104° or 105° F. with a tendency to remain there, means that we
have a severe infection to deal with. I find it a safe rule not to
allow the temperature to go much above 104° F. A higher tem-
perature than this necessitates an overworked heart. For the pur-
pose of controlUng the temperature, a fifteen-minute sponging every
hour with water at 90° F. may be tried.
Packs. — If sponging does not answer, the pack (page 481) should
be brought into use. vSimply because the child has a rash is no contra-
indication to the application of moderate cold to the skin. The pack
may be used in scarlet fever just as in pneumonia or typhoid fever.
The fear that the disease may "strike in" and kill the patient is one
of the many inexpHcable ideas of the laity with no foundation in
fact. The child is placed in the pack at 95° F. It will rarely be
necessary to reduce the temperature of the pack below 80° F. If
the case is of the fulminating type with persistent high temperature,
it may gradually be reduced to 70° F. In reducing the temperature
of the pack, the towel is not to be removed from the patient. He is
turned from side to side and the towel moistened with water at the
31'
CONTAGIOUS DISEASES
desired temperature. Time and again I have seen children who
were tossing about the bed deHrious and sleepless, fall into a quiet
sleep when placed in a pack. With a reduction of the temperature,
there is a corresponding diminution in the pulse-beats of from twenty
to thirty a minute. When we think what a saving this is to the work
of the heart, its benefit is most apparent.
Tub-baths. — The full tub-bath at a temperature of 95° F. for ten
minutes at the commencement of a case in which there is a great deal
of restlessness and irritability, will often act most satisfactorily in
quieting the patient. Tub-bathing, however, requires a great deal
of handling of the patient, and in the cases in which there is a
persistent high temperature, and in those in which it mounts up
suddenly after the bath, the pack is by far the more satisfactory.
Oil Inunction. — The itching and burning of the skin in scarlet
fever are most distressing. This also is relieved to a considerable
degree by the pack. The child's comfort will also be greatly en-
hanced by an inunction twice daily of cold-cream or liquid albolene.
Vaselin or olive oil may be used, but they are much less satisfac-
tory. Vaselin will act as an irritant to some sensitive skins.
During the period of desquamation the oily applications largely
prevent a free distribution of the scales, and thus Umit the chance of
infecting others through the clothing and other objects in the room.
Heart Stimulants. — If, during sleep, the pulse is over 150 a min-
ute with a weakened first sound, a heart stimulant is necessary. For
a child one year of age, one drop of tincture of strophanthus at two-
hour intervals, or an equal amount of the tincture of digitalis, should
be given. On account of its being well borne by the stomach, the
tincture of strophanthus is always preferred. Strychnin is a remedy
of considerable value as a heart stimulant. When the pulse is soft
and the heart action shows a tendency to irregularity, 2^0 grain may
be given every two to four hours to a child from one to three
years of age, and yi^ grain to a child from three to six years of age,
at intervals of from two to four hours. Alcohol should be used only
in the septic, asthenic cases when other means of stimulation have
failed. In such instances it should be used freely. In a few cases I
have used it in very large quantities with striking benefit. Begin-
ning with one-half dram of whisky every two hours, it may be in-
creased gradually until its beneficial effects are noticed on the heart
action. It is astonishing how much alcohol may be given, in a pro-
foundly septic case, without the slightest effect, except an improve-
ment in the heart action, and a corresponding improvement in the
child's general condition.
Care of Throat and Nose. — The throat and nose demand our at-
tention during the acute stage. For the nose toilet in older children,
a solution of menthol and hquid albolene is used by means of an
atomizer (Fig. 34) and in the very young by instillation with a
medicine-dropper. A forcible syringing of the nose in a young child
SCARLET FEVER
319
is not a safe procedure even in the most skilled hands. Local treat-
ment of the throat depends entirely upon its condition. If the
mucous membrane is swollen, edematous, and covered with a glairy
mucopurulent secretion, or if there is a pseudo-membrane, or if there
is much pain or discomfort upon swallowing, local treatment is re-
quired. The child is made to gargle, if old enough, or, what is far
better, the throat is irrigated with hot saline solution, at 120° F.
This is done as is described on page 238. Force will be required
in the very young. In older children, the relief from pain that is
experienced by free irrigation is so great that usually the child takes
the tube in its mouth gladly for the future irrigations. The use of
antiseptic gargles and washes has not seemed to me to possess any
Fig. 34.— The de Vilbiss Oil Atomizer.
value other than that of cleanliness, and free douching accomphshes
this in a far more satisfactory manner.
Complications. — Cervical Adenitis. — Cervical adenitis is a very
frequent complication of scarlet fever. With the first sign of a
swollen gland, apply an ice-bag and keep it constantly apphed day
and night. If this is not possible, apply 30 percent ichthyol in zinc
ointment, which is kept bound on the parts, the appUcation being
renewed every three hours. Cataplasma kaolini may also be used.
It is spread on a piece of linen and applied over the swollen area. It
should be renewed at six-hour intervals. Whether the ice-bag, the
ichthyol, or the emplastrum kaolini is used, Crede's ointment may be
given a trial, ten grains being rubbed into the skin over the swollen
gland for fifteen minutes twice daily.
Otitis. — Otitis is a comphcation in from 10 to 30 percent of the
cases of scarlet fever. In view of the grave possibilities of mastoid
320 CONTAGIOUS DISEASES
involvement, sinus thrombosis, and jugular bulb infection, the pres-
ence of pus in the middle ear should be promptly detected, and the
pus evacuated by a free incision of the drum membrane. The pres-
ence of middle-ear infection may be suggested by a pain or a sensa-
tion of fullness in those old enough to locate it. In infants, restless-
ness, sleeplessness, or tenderness on manipulation in cleansing the
ears may be the only objective signs of the trouble. In the majority
of my cases of otitis, none of the above signs of pain and discomfort
were present. The ear involvement was suggested because of a contin-
ued elevation of temperature which could not otherwise be accounted
for. With a persistent elevation of the temperature of unknown
origin following scarlet fever, the ears should be examined by an ex-
pert in otoscopy. As a routine measure during the fever, the condi-
tion of the drum membrane should be noted at least every second day.
As stated above, otitis develops in from lo to 30 percent of the
cases, depending somewhat upon the character of the epidemic, but
more upon the age of the patient. The younger the child, the
greater the danger of ear involvement. Many cases of deafness
which we meet had their origin in an attack of scarlet fever, and are
due to somebody's ignorance or neglect. Among 185 cases of scarlat-
inal otitis, reported by Bezold and quoted by Holt, in 30 there was
entire destruction of the membrana tympani; in 59, the perforation
comprised two-thirds or more of the membrane; in 13, there were
small perforations; in 44, there were granulations or polypi; in 15,
there was total loss of hearing on one side, and in 6 of the cases upon
both sides; in 77, the hearing distance for low voice was less than
twenty feet. May, of New York, has collected statistics of 5613
deaf-mutes, of whom 572 owed their condition to otitis following
scarlet fever. When we consider how many cases of permanent ear
defects have occurred and do occur every year as a result of careless-
ness or lack of even an elementary knowledge of aural diagnosis, we
do not feel inclined to congratulate the members of the medical pro-
fession as to their ability to complete their cases. The bacteriology
of scarlatinal otitis is the same as in suppurative otitis developing
with or following any other infectious disease, except that there is a
greater tendency to severity because of the liability to streptococcus
infection. Prompt relief demands prompt recognition of the con-
dition of the drum membrane, with evacuation of the pus and suitable
after-treatment. (See Acute Suppurative Otitis, page 420.) This
will not be possible if the practitioner does not examine the ears or is
not sufficiently expert to recognize a diseased condition when he sees it.
Cardiac Involvement. — Heart complications are not particularly
frequent in scarlet fever. Nevertheless the heart should be examined
daily. In my own observations, they have been present in about 2 per-
cent of the cases. The treatment is laid down elsewhere under appro-
priate headings.
WHOOPING-COUGH — PERTUSSIS 32 I
Nephritis. — Early in the cases of severe infection there will often be
discovered a transient albuminuria with a few hyaline casts. There
may be slight suppression of the urine. In but one of my cases was
there complete anuria at this stage of the disease. Within thirty-six
hours after the first sign of the disease, the kidneys ceased to act, and
the child died on the third day, from the acute diffuse nephritis. The
condition of the kidney giving rise to albuminuria is best reheved by
attention to the skin function by the use of a bath at a temperature
of 105° F. every six or eight hours. The child may remain in the
bath for ten minutes, during which time the skin should be vigorously
rubbed with the bare hand. The tincture of aconite in doses of one
drop, with five drops of sweet spirits of niter for a child eighteen
months of age, will usually produce a satisfactory skin action.
What is known as scarlatinal nephritis rarely appears before the
third week of the disease. I have known cases to occur as late as the
sixth week. The management of this complication will be found on
page 343-
Arthritis as a complication of scarlet fever is seen in onlv a few of
the cases — about 3 percent. There may be swelling or redness of the
parts, or both these symptoms may be absent. Whether the swelling
is present or not, the joints are very painful on manipulation. Affected
joints should be wrapped in old hnen, saturated with a lead and
opium solution, and the dressing renewed every six hours. The fol-
lowing lotion has answered well in a few cases :
I^. Mentholis o ij
Tincturse opii 5 iv
Spirit! vini recti q. s. ad 5 vj
Soft linen is moistened with the lotion and wrapped about the parts
and covered with oiled silk or rubber tissue. The part affected is then
wrapped in flannel or cotton-wool. The lotion may be freshly applied
at intervals of from four to six hours. The only objection to its use
is the odor of the menthol. Internally, to a child four years of age,
aspirin may be given in doses of five grains, with ten grains of the
bicarbonate of soda at four-hour intervals, four doses being given in
the twenty-four hours. Salicylate of soda may be used in small
doses; but, as it may be badly borne by the stomach, aspirin is
preferable.
WHOOPING-COUGH— PERTUSSIS
As an infectious disease of importance, pertussis may be classed
with diphtheria and scarlet fever. It is probably the cause of more
deaths todav than is any other infectious disease. It does not kill
directly through the means of a specific poison, as do diphtheria and
scarlatina; but, on account of its prolonged course and its many
complications, it is equally effective as a life-destroyer.
Susceptibility. — That pertussis is one of the most infectious of dis-
322 CONTAGIOUS DISEASES
eases is well illustrated by the following history : On a bright cold day
in December a patient of mine, nine months of age, passed in its car-
riage on the street a child of about the same age who had pertussis.
This child was also in its carriage. My patient took the disease. There
was no other possible source of infection. That pertussis may be
conveyed through the medium of the clothing of a second person is
exceedingly doubtful. Direct exposure seems necessary for infection
to take place. The period of infection dates from the beginning of
the catarrhal stage, and lasts for two or three weeks from the cessa-
tion of the paroxysms. The period of incubation is from seven to
fourteen days.
When pertussis breaks out in a school or in an institution for
children, it is practically impossible to prevent an epidemic. This
is because the disease is infectious during the early catarrhal stage,
which lasts from one to two weeks. During this time the only symp-
tom is a cough, and perhaps a sHght degree of bronchitis, such as we
meet in a common cold.
The previous state of health appears to exert no influence as far
as the susceptibility is concerned. The strong and the delicate are
alike predisposed to infection. The very young and the adult are
less liable to take the disease. From the fourth month to the third
year is the most susceptible time of life. Cases have been reported
in children one week old. Any other concurrent infectious disease
exerts no influence upon the course of the pertussis. It has been
claimed that the advent of diphtheria or scarlet fever during an
attack of pertussis shortened and modified the course of the per-
tussis. My experience does not corroborate this statement. Other
affections, which may develop during an attack, simply increase the
burden to be borne by the patient. The largest number of cases de-
velop during the warmer months, from May to November. This
may be accounted for in part by the fact that at this period of the year
the infected child comes more frequently in contact with its unpro-
tected neighbor. It tends to disprove, however, that catarrhal affec-
tions of the respiratory tract predispose to the disease, as respiratory
affections in the young during the warmer months are notably rare.
The normal mucous membrane of the healthy offers no greater re-
sistance than does the diseased structure of the ailing. We have, in
the early stages of pertussis, not simply a bronchitis, as has been
claimed, but a catarrhal process due to a specific infection.
Interesting observations relative to susceptibility to measles and
pertussis were made by Biedert. After an absence of sixteen years,
both these diseases broke out in a German village at about the same
time. There were 401 children in the village under fourteen years
of age. These children had never been far from home, and not one of
them had had either measles or pertussis. Of this number, 344
WHOOPING-COUGH — PERTUSSIS 323
came down with measles and 366 with pertussis, 340 having both
diseases at once.
The susceptibihty of these unprotected children to pertussis was,
therefore, 95.5 percent; to measles, 85.8 percent. The ages of those
who escaped pertussis were as follows: Seven were under five years
of age ; four between five and ten years ; nine between ten and four-
teen years.
Complications. — The complications of pertussis are many, and it
is through them that the disease is so destructive to Hfe. The mor-
tahty of pertussis is generally estimated at from 4 to 6 percent.
That it is actually much higher than this is well known to every one
who has seen much of the disease. The most fatal complication is,
in winter, bronchopneumonia, and, in summer, gastro-enteric disease.
Convulsions are not an infrequent complication and may be fatal.
Malnutrition often follows a severe attack in the delicate bottle-fed
children, thus paving the way for intercurrent disease. Tuberculosis
not infrequently follows a prolonged attack of pertussis. Blindness,
deafness, and motor disturbances have all been observed during attacks
of pertussis, which resulted in complete recovery. These cases may
be explained as follows : During a severe paroxysm the cerebral cir-
culation is greatly disturbed, resulting in a moderate congestion or
venous hyperemia, which produces a disturbance of nutrition in
certain portions of the brain. With the return to the normal, these
symptoms all disappear.
Diagnosis. — The diagnosis of pertussis is most dii^cult in the
early stages, before the whoop or the convulsive nature of the
paroxysm develops. Even a spasmodic cough does not alwavs mean .
that we have a developing pertussis. The cough, if more troublesome
at night, favors a diagnosis of pertussis. Further, if we have a
pertussis to deal with, the cough grows steadily worse, and resists all
the usual methods of treatment, the whoop soon establishing the
diagnosis. In rachitic children, and in those in whom the nerv^ous
element is prominent, the cough of an ordinary cold is often of a de-
cidedly paroxysmal character, especially when there is an acute or
subacute laryngitis. The mild cases are also difficult of diagnosis.
Illustrative Cases. — Recently two patients, aged eight and ten
years respectively, went through an attack of pertussis with but two
or three severe paroxysmal coughing attacks. Two other cases seen
in private practice show also how mild the course may be : The pa-
tients, brother and sister, aged six and eight years respectively,
commenced coughing about ten days after exposure. The cough
was paroxysmal, with from three to five seizures in twenty-four
hours. The boy whooped only three times during the entire course
of the disease; the girl never whooped at all. Vomiting never oc-
curred with a paroxysm. Both coughed six weeks. These children
had neither adenoids nor bronchitis.
324 CONTAGIOUS DISEASES
Often the very young and the very delicate do not whoop even
during a severe attack. Among the severe cases, convulsions and
hemorrhage from the nose, ears, and eyes, were seen from time to
time. A very severe seizure in a girl nine months old was followed
by small extravasations of blood into the skin of the entire body.
In all cases of severe cough of uncertain origin, the nasopharyngeal
vault must always be examined for adenoid growths. This, in
young children, can properly be done only by the use of the index-
finger.
Pertussis in children under eighteen months of age must ever be
regarded in a serious light. Delicate and rachitic children should be
carefully guarded against the disease. Bronchopneumonia and
gastro-enteric troubles are the most frequent compHcations among
this class of children. The majority of healthy children over eighteen
months of age bear an attack without any great inconvenience.
Treatment. — In considering the management of pertussis we are
iirst to remember that the disease is self -limited, that it cannot be
cured by treatment, and that, in common with the other infectious
diseases, all we can do is to make it as easy as possible for the pa-
tient to bear. We cannot shorten the attack, but we can lessen the
number and severity of the paroxysms. This is to be accomplished
by the use of drugs administered by the mouth. The rubbing of a
few drops of Roache's embrocation on the stomach is, of course,
valueless. The believers in the theory that the chief seat of trouble
is in the nose, have advocated and brought into use the insufflation
of various kinds of powders, prominent among which are boric acid,
resorcin, and ground coffee. This treatment, as might be expected,
is of no service.
During a three years' epidemic of whooping-cough in the
Country Branch of the New York Infant Asylum, from sixty to
ninety children were constantly in quarantine. New cases developed
about as rapidly as the old ones were discharged. During the epi-
demic children were quarantined who did not have the disease. On
the other hand, an early diagnosis was frequently made before the
onset of the spasmodic stage, by excluding all possible causative fac-
tors, such as pharyngitis, larvngitis, and bronchitis.
The cases as they developed were divided into groups of twenty.
They were allowed to cough untreated until the height of the par-
oxysmal stage was reached. This usually required from ten to four-
teen days from the commencement of the cough. Careful record
was kept day and night of the number and severity of the paroxysms.
When there was no increase either in number or severity for three
days, we believed the height of the paroxysmal stage had been
reached, and the drug selected was brought into use. The ages of the
cases treated varied from six weeks to twenty-six years. Only three
patients had reached adult life. Five-sixths of the patients were
WHOOPING-COUGH — PERTUSSIS 325
under four years of age. One-half were under two years. The dura-
tion of the attacks ranged from three to twenty weeks. From six to
eight weeks was the usual duration. In several the attacks were so
mild that a diagnosis was difficult.
Drugs. — The drug treatment consisted in insufflations, internal
administration, and inhalations. The treatment in which drugs did
not enter was in the use of the steam spray and fresh air. Resorcin
and boric acid combined with bicarbonate of soda were used bv means
of insufflations in six test institution-cases, and discontinued after
three days. The treatment was found impracticable and useless.
Inhalations of vapo-cresolene were used in ten other institution-cases.
Apparently it had no effect whatever in modifying the disease. In
private practice vapo-cresolene has sometimes a decided sedative
influence upon the disturbed nervous state of the parents and does
not harm the child! It has been used with my permission in many
private cases. Medicated steam inhalations, creosote, turpentine,
and wine of ipecac were used in many cases with decidedly beneficial
results. The cases selected for the inhalations were those of the
very young and delicate, with a complicating bronchitis, the steam
being used in connection with other treatment. The drugs selected
for internal administration were alum, fluidextract of horse-chestnut
leaves, dilute nitric acid, hydrochlorate of cocain, bromoform, quinin,
the bromids, belladonna, and antipyrin.
The fluidextract of horse-chestnut leaves and dilute nitric acid
were each used in twenty test institution-cases. After a trial of
five days they proved valueless, or objectionable on account of the
vomiting produced, and were then discontinued. Alum appeared to
be of some service, but it was badly borne by the stomach. Bromo-
form was used in sixteen dispensary and in six private patients. In
three only did it appear to be of service.
One-tenth grain of hydrochlorate of cocain every four hours for a
child two years of age was employed in twenty-three dispensarv and
in five private cases. It possesses some value in controlling the
severity of the paroxysms, but the results were not sufficiently
marked to warrant its further use.
Quinin has been used in a large number of cases, in both private
and out-patient work. I find that great benefit may be derived from
its use if a large amount can be given. Its administration, how^ever,
is attended with difficulties. Twelve to twenty grains in twenty-
four hours are required for pronounced results in children from two
to six years of age. The administration of such a large amount of
this well-known drug is not favorably received by many parents.
Our inability to make it palatable is a serious drawback at any age,
and almost excludes its use in the very young ; furthermore, in the very
young and delicate, it is apt to derange the stomach and produce
vomiting. If given in solution it is best to use the bisulphate in
326 CONTAGIOUS DISEASES
yerberzine (Lilly). In older children, when quinin can be given in
sufficient quantities in capsules, the improvement as to the number
and severity of the paroxysms is sometimes surprising.
Belladonna was used in sixty test institution-cases. It was be-
gun at the height of the paroxysmal stage. It was administered to
the point of physiologic effect for a period of from five to seven days
without influencing a single case of whooping-cough in the slightest
degree. True, the cases were all severe, but they responded promptly
to other means used later. The children were all between three and
seven years of age. I have repeatedly seen these children with
dilated pupils and the characteristic belladonna blush, grasping a
crib or a chair for support during a paroxysm that furnished an ideal
clinical picture of the disease.
Equal quantities of the bromids of sodium, ammonium, and po-
tassium were used in sixty test institution-cases. The results, con-
sidered from all standpoints, were better than with any of the means
of treatment thus far referred to. The severity and duration of the
paroxysms were especially influenced, although the number of
seizures was practically unchanged. From twelve to sixteen grains
in twenty-four hours were given to a child one year of age. When
given in syrup of raspberry on a full stomach, or with plenty of water,
there is very little disturbance attending its use. For a child two
years of age, sixteen to twenty-four grains may be given daily,
Antipyrin was used later in sixty test cases in the institution, as
well as in out-patients and in private work, I have given antipyrin,
combined with bromid of soda, in over six hundred cases of pertussis.
The antipyrin was given under the same conditions as those already
referred to, combined with syrup of raspberry,
i^. Antipyrinae gr. xviij
Sodii bromidi gr. xxx
Syr. rubi idaei". " 5 v
Aquae q. s. ad oij
M. Sig. — One teaspoonful every two hours, six doses in twenty-
four hours, for a child fifteen months of age.
Antipyrin is readily taken and easily borne by the stomach — two very
desirable requirements in a drug that is to be given to a child for a
considerable time. It is not depressing when given with any degree
of intelligence — in fact, it is well borne by children when given in good-
sized doses, and it controls whooping-cough better than does any
other drug I have ever used. Its beneficial effects are as follows:
The paroxysms are diminished in number from one-third to one-half
without any amelioration of an individual seizure, or the seizures may
be less severe without any diminution in their number. In some,
both the severity and the number of the paroxysms were favorably
influenced. In all the cases the effect of the drug was beneficial,
Antipyrin gave the best results of any drug used alone. The
bromids took the second place. We then combined the two and used
WHOOPING-COUGH — PERTUSSIS 327
them in forty institution-cases. We soon learned that the two drugs
given together more effectively controlled the disease than when
either was given separately. In combination they gave satisfaction
in the large number of cases previously referred to. At the out-
patient department of the Babies' Hospital we use the drugs com-
bined in the form of a compressed tablet. For a child eight months
of age one-half grain of antipyrin with two grains of bromid of soda
are given at two-hour intervals — six doses in tw^enty-four hours; for
a child of fifteen months, one grain of antipyrin and two and one-
half grains of bromid of soda at two-hour intervals — six doses in
twenty-four horurs; from the fourth to the eighth year, two grains
of antipyrin and five grains of bromid of soda at two-hour inter-
vals— six doses in twenty-four hours.
Codein is used only in the most severe forms of pertussis, when
other means fail to relieve the patient. One of the most troublesome
features of the disease, in fact, a dangerous feature, is the wakefulness
at night caused by repeated attacks of coughing and vomiting. When
the child cannot sleep, I give codein independent of the other treat-
ment, whatever it may be. For a patient five years of age, one-
sixth grain is given at bedtime and repeated during the night when-
ever the paroxysms require it. For a child from eight to twelve years
of age, one-fifth grain may be given at bedtime and repeated twice if
necessary. For a child from two to three years of age, one-tenth grain
may be given and repeated not oftener than twice during the night.
The drug should not be continued longer than a week or ten days. I
have never seen unpleasant effects follow its use.
It will be observed that the drugs of value in whooping-cough are
the sedatives. It is well known that by the prolonged use of seda-
tives their effect is lost. For this reason I have found it wise to use
what may be called ' * interrupted medication. ' ' For five days the anti-
pyrin and bromid of soda are given, then stopped, and full doses of
quinin are given for five days, when the antipyrin and bromid are
resumed. In this way, giving the drugs five days each, we continue
with advantage for a month or six weeks. It is rarely necessary to
continue the treatment longer than six weeks ; usually from three to
four weeks is sufficient. Of course, the child will whoop after that
time, but the active stage of vomiting and severe paroxysms will be
over. If the vomiting can be controlled in an attack of pertussis,
and if the patient can obtain sufficient sleep, much has been accom-
plished. I would emphasize here, what has already been suggested:
Do not begin the specific whooping-cough treatment, whether by the
administration of quinin, antipyrin, or other remedies, until the spas-
modic stage is at its height. If a sedative is given as soon as a diag-
nosis is made, by the time the disease reaches its height tolerance will
have become so established that the drug will have lost not a little of
its sedative action. If medicines must be given during the earliest
328
CONTAGIOUS DISEASES
stage, a placebo may be used. The Infant Asylum patients, upon
whom the best of our observations were made, received distilled
water colored with compound tincture of cardamom.
Steam inhalation is referred to only to call attention to its value
when used in connection with the drug treatment. It has been
of great service in the very young, and among those who have
complicating bronchitis and bronchopneumonia. I prefer the
Arnold steam atomizer (Fig. 35). The nozzle is placed about eight
inches from the face, which alone is exposed, the other parts of the
body being well protected by a rubber sheet. The inhalations, when
taken from fifteen to twenty minutes every two hours, often give
a weakly, cyanosed patient marked relief. I have used wine of ipecac,
creosote, and turpentine in the water thus vaporized, as mentioned
before; but I am not convinced
that they offer any advantage
over plain steam.
Fresh air is of immense value
as a means of relief in whooping-
cough. We are told that the
child rarely coughs when out of
doors, but commences as soon
as he is brought into the house,
which is usually overheated and
badly ventilated. In nearly all
cases the cough is worse at night.
This may be explained in part
by the absence of proper ventila-
tion in the sleeping apartment.
Many out-patient mothers tell
me that remaining for hours
with the child near a gas tank relieves the whooping-cough, and it
doubtless does. There is a vast difference between the comparatively
pure air in the vicinity of the gas tank and the air of the average tene-
ment. I always encourage the gas-tank treatment. A child who for
any reason must remain indoors should not be allowed to remain con-
stantly in one room. There should be two rooms, every window in
the one not in use being freely open. The living-room and sleeping-
room should be kept at a fairly even temperature — from 68° to 70° F.
The Kilmer Belt. — A few years ago Dr. T. W. Kilmer, of New
York, conceived the idea that a belt around the child's body producing
firm pressure, would support the abdomen sufficiently during a
coughing paroxysm to prevent vomiting. The Kilmer belt (Figs. 36
and 37) was the outcome. I have used the belt in a considerable
number of cases; at first with a great deal of skepticism, watching
the patients upon whom it was used at my clinics at the out-patient
department at the Babies' Hospital and at the New York Polyclinic,
Fig. 35.— The Arnold Ste.\m Atomizer.
WHOOPING-COUGH — PERTUSSIS
329
where records were kept of the number of vomiting seizures in twenty-
four hours, for three days before applying the beh, and the further
record after the belt was in use, together with the statement of the
mothers and oftentimes of the children themselves. These records
convmced me that the belt has a field of usefulness in the management
of whoopmg-cough. I later adopted it for use among my private pa-
tients. Like most remedial measures, however, its use is not always
attended with success. I have applied the belts without the slightest
benefit in some vomiting cases. Usually, how-
ever, it is of service in relieving the vomiting.
In some the vomiting has entirely ceased after
the belt was applied. I believe' it should be
given a trial in every severe case, particularly
where the vomiting is a very prominent symp-
Fig. 36. — The Kilmer
Belt.
Fig. 37.— The Kilmer Belt in Position.
tom, and in infants in whom the drug treatment is unsatisfactory.
The belt,^ which has been improved from time to time, is made of
hnen, with pieces of rubber elastic at those portions which rest against
the sides of the child. There are eyelets in each end for the purpose
of lacmg the belt together. It is best to apply it over the nether-
most garment.
"The belt is made by J. Jungmann, New York. In taking a measurement
taken ''T";f'."H 1'^" "'^^T" '1'^?""^ '''' "^"^^ prominent parts should be
taken. This with the age of the child should be sent to the manufacturer.
330
CONTAGIOUS DISEASES
MEASLES
Measles is a disease which few of the human race escape. In itself
it cannot be considered a dangerous disease, for when uncomplicated,
it is almost never fatal. On account of its tendency to respiratory
complications, however, particularly in the young and the feeble, it is
indirectly one of the most fatal diseases. During the year 1906, 441
deaths due to measles occurred in Greater New York — 58 more than
were caused by scarlet fever.
Popular Misconceptions. — Grave errors exist among the laity,"
and perhaps among a few physicians also, as to the proper manage-
ment of the more severe exanthematous diseases, and as the measles
patients suffer most from this failure properly to appreciate existing
conditions, it is not out of place to speak of them here.
The popular conception as to the management of measles is that
the patient should be warmly wrapped, given hot drinks, and kept
in a dark room with little or no ventilation. An attack of measles
renders the child, for the time being, a very susceptible subject for
bronchopneumonia. The younger or the more delicate the child,
the greater the danger. The dark room with its closed windows and
doors and dust, the extra wrappings with the resulting heat "consti-
pation," and the reduced vitality, do much to prepare the way for
that which we most dread in an attack of measles, viz., a possible
bronchopneumonia ; for in measles one danger-signal is up constantly
throughout the attack, and it always reads pneumonia.
Complications. — In children's institutions today measles is dreaded
more than diphtheria and more than scarlet fever, for the reason that
when an epidemic breaks out, because of its marked early contagious
characteristics, it means, in all probability, many cases and many
deaths. In an epidemic in one of the New York institutions for chil-
dren, a few years ago, there was a death-rate of 40 percent from
measles complicated with bronchopneumonia. Having been through
many epidemics of measles in children's institutions, and having seen
many cases in private and complicated cases in consultation, I am
convinced that in this disease we have an illness which should inspire
much greater respect on the part of the physician and demand the
highest intelligence on the part of both physician and the family in
order that it be managed to the best interest of the patient. Sup-
purative otitis is a fairly frequent complication ; nephritis is a rare
one.
Pneumonia is an infectious disease. In measles an inflammation
of the mucous membrane of the respiratory tract is a part of the dis-
ease. We have thus prepared for us a most favorable soil for the
development of pathogenic bacteria that may be inhaled through the
mouth or nose. Given a dust-free room, advisedly ventilated, and
we would have comparatively few cases of measles-pneumonia.
MKASLES 331
Treatment. — General. — A child ill with measles should be com-
fortably clad in the usual night-clothes and kept in bed. No extra
wraps are required ; neither is it desirable to keep the room at a higher
temperature than is customary; 68° to 70° F. is a suitable room
temperature. There are many gradations of Ught between glaring
sunUght and utter darkness. Both are extreme, and one almost as
undesirable as the other. It is my custom to advise that a window-
shade of dark green be lowered within one foot of the window-sill.
The light brown or drab shade should be lowered completely. If
the shade is white or a very light color and not protected by a
curtain of dark material, it will be necessary to exclude the bright
light by some other means.
The patient should be put on a reduced diet. If bottle-fed, the
milk mixture should be diluted at least one-half bv adding boiled
water, the same quantity being given as in health. This usually
will be required only during the first few^ days of the acute febrile
stage. Patients with measles are given water to drink freely at a
temperature not lower than 50° F. For "runabout" children, eigh-
teen months of age and over, the diet as suggested for the sick (see
page 133) should be given.
There should be one evacuation of the bowels daily. An enema
should be given when this does not otherwise take place. The urine
should be examined for albumin every second day.
During the waking hours the eyes should be generously bathed
every hour or two with a 3 percent solution of boric acid, using old
linen, which is afterward destroyed.
Symptomatic. — The temperature of uncomplicated measles is
rarely high enough to call for special interference. If it should have
a tendency to continue above 104° F. for eight or ten hours and the
child be uncomfortable and restless, a tepid sponge-bath may be
given, the duration of which may be from ten to twenty minutes,
and repeated at intervals of two or three hours. Whether the fever
demands it or not, the patient should be sponged twice a day with
tepid water at 100° F. He is then dried and an appUcation of
cold-cream, liquid albolene, or olive oil is made to the entire body.
This is given for the sole reason that it relieves the itching, induces
sleep, aids digestion, reduces the temperature, and enables the child
to pass through the disease with less discomfort.
Now and then a case is encountered in which the rash is slow in
appearing. The temperature is high, 104° to 105° F., the skin hot
and dry, and the child very uncomfortable, perhaps delirious. In
such patients a hot bath, 105° F. to 110° F., of from three to five
minutes' duration will often bring out the rash, greatly to the relief
of the symptoms, w^hich may have been of an urgent character.
The cough of measles during the active period of the attack is one
of the annoying features of the disease, and some relief must be
332 CONTAGIOUS DISEASES
attempted, particularly if the child is kept awake at night by it.
The ordinary expectorants alone are of no service in a measles cough.
A sedative only will give relief. For a child six months of age, from
five to eight drops of paregoric may be given, and repeated after an
interval of two hours, if necessary. The following combination of
paregoric and sweet spirits of niter is often of service :
I^. Tincturae opii camphoratae gtt. x
Spirit! etheris nitrosi gtt. iij
M. Sig. — One dose; to be repeated every two or three hours, for
a child of eighteen months or older.
From the first to the second year ten to fifteen drops of paregoric
may be given at two-hour intervals, if required, or one-half grain of
Dover's powder may be used. Usually, it will be necessary to give
but two or three doses of the sedative during the night. Should the
paregoric or Dover's powder be objectionable because one may dislike
to give opium to young children, from three to four grains of sodium
bromid in two drams of water, repeated as required every hour or
two, will be of service for a child under two years of age. From the
second to the fifth year one grain of Dover's powder, or from fifteen
to twenty-five drops of paregoric, or j-q to ^ grain of codein, may be
given at intervals of from two to four hours.
If bronchitis develops sufficiently to require treatment, as it does
in at least one-half the cases, the means for the management of bron-
chitis suggested on page 258 will be found useful. The temperature
of a child ill with measles should be taken three times daily and the
lungs and heart should be examined every day. It is my custom to
keep the air of the sick-room moistened with vapor during the entire
illness. Its benefits are twofold. It relieves the cough, as it is more
agreeable to the congested mucous surface during the early stage, and
prevents the free circulation of dust, the danger of which has already
been referred to. If the room is carpeted, it should be well sprinkled
with water before sweeping. It is much better if the floor is bare, as
the broom can then be dispensed with and a damp cloth used instead.
The length of the quarantine is usually from twelve to sixteen days,
at least ten days of this time being spent in bed.
Otoscopic examination should be made every second day until
the case is discharged. In the event of a sudden rise in tempera-
ture during convalescence, which cannot be explained by the con-
dition of the intestines, lungs, or throat, such an examination should
be made by an expert.
CHICKEN-POX— VARICELLA
Chicken-pox is a disease for which very little treatment is re-
quired. During the eruptive period and until the stage of vesicula-
tion is passed and crusts have formed, it is well to keep the young
child in bed. Older children will find such confinement irksome.
GERMAN MEASLES — RUBELLA 333
and they may be allowed to be about the room, but should not be
allowed to go out of doors. During an attaek of chicken-pox the
child is more sensitive to exposure, and while complications, such as
nephritis, are rare, one of the worst cases of acute nephritis which it
has been my lot to treat developed as a sequela of chicken-pox.
The itching is the most annoying feature of the disease, as it causes
restlessness, loss of sleep, and, through the child's attempts at secur-
ing relief by scratching, opens up the possibility of grave skin in-
fections. In out-patient work I have repeatedly seen extensive
furunculosis follow an attack of chicken-pox. In two institution-
cases erysipelas developed, and in two others dermatitis gangrenosa
was a sequela. During the stage of active eruption the child should
not be given a tub-bath, gentle sponging with a tepid solution of
boric acid — two heaping tablespoonfuls of boric acid to one-half
gallon of boiled water — answering the purpose of cleanliness for a
few days. After the daily sponging, and several times during the day,
the areas affected are anointed with a 10 percent boric acid oint-
ment, made with cold-cream as follows :
I^. Pulveris acidi borici gr. c
Unguenti aquae rosae q. s. ad oij
The boric acid ointment relieves the itching to a marked degree
and doubtless is of value in preventing local skin infection. An
equally effective remedy, but one less agreeable for domestic use, is a
lotion composed of 5 percent ichth^ol and sterilized olive oil. This
is applied to the entire body twice daily after the bath. Objections
to its use are the odor and the staining of the clothing and bed-linen.
Permanent scars at the site of the vesicles are so rarely seen that no
special precautions are required on this account. The duration of
the attack, from the beginning of the period of eruption until the
crusts fall, is usually about three weeks. The child should be con-
sidered in quarantine and not allow^ed to come in contact with the
unprotected, until the skin is clear.
GERMAN MEASLES— RUBELLA
German measles requires ordinarily very Uttle treatment. About
two days in bed, a few more days in the house with a reduced diet,
and free bowel action, is usually all that is needed, recovery being
complete in from six to eight days from the beginning of the attack.
The enlargement of the post-cervical glands and the associated pain
may be reheved by applications of a 25 percent ichthvol ointment on
strips of linen firmly held in position. The emplastrum kaohni
may also be used in the same manner with equally beneficial re-
sults. Where either is used, the dressing should be changed every six
hours.
334 CONTAGIOUS DISEASES
MUMPS ; EPIDEMIC PAROTITIS
Mumps is a contagious disease of the "runabout" age of child-
hood. The seat of the operation of the infection is the parotid gland.
One or both glands may be involved. Often the involvement of one
gland is three or four days in advance of the other. The period of
incubation is a long one — usually from two to three weeks. The
duration of the disease, from the commencement of the swelling until
it has completely subsided, is about ten days. It is rarely longer
than this when both glands are involved at the same time.
Treatment. — During an attack the child should be kept in bed
until the temperature is normal. He should remain in the house
until the swelling has entirely subsided. He should be put on a
reduced diet of broths, gruels, and milk, as in any illness with
fever. Fruits and acids should not be given because of the discom-
fort they occasion to the patient. The bowels should move once
daily. When this does not occur, citrate of magnesia or a SeidHtz
powder should be given.
The temperature rarely requires interference. If it reaches 104°
F., twenty minutes' sponging with one-fourth alcohol and three-
fourths water at 80° F. will usually control it. Relief of the pain
and tension, which are most severe in some cases, is best secured by
warm wet dressings. A table napkin wrung out of water at a temper-
ature of from 110° to 120° F., and placed over the parts, is a conve-
nient method. The warmth and moisture will be better retained if
oiled silk or rubber tissue is placed over the dressing. The appHca-
tion should be changed every twenty or thirty minutes. During the
night or at other times when the frequent changing would disturb
the patient warm camphorated oil on a piece of flannel which is
bound to the parts will usually be agreeable to the patient.
Complications. — Complications in mumps are rare. Orchitis is
occasionallv seen in boys, but it rarely occurs if the patient is kept
in bed. Infection of the parotid gland, other than that of the spe-
cific poison, is extremely rare. I have never seen a case of so-called
mixed infection. Nephritis is a rare complication in mumps. I
have seen one case of this nature.
Errors in Diagnosis. — Errors in the diagnosis of mumps occur
very frequently. A great many cases of acute adenitis are diag-
nosed as mumps. When getting the history of the previous illnesses
in out-patient or private work, we are not infrequently told that
the child has had two or three attacks of mumps, which means
that he may have had one attack, the other supposed attacks
being acute adenitis. It has occurred to me that probably some of
these cases which were diagnosed as mumps were due to an infection
which had extended to the parotid from the adjacent lymph-glands.
THE URINE
Tables dealing with the frequency of urination and the specific
gravity of the urine for the different ages of childhood are neces-
sarily inaccurate, particularly when they refer to children under one
year of age.
Urinary Observations. — At the New York Infant Asylum a few
years ago, Dr. George T. Myers, at that time resident physician, made
a series of investigations under my direction as to the various phases
and functions of the newly born infant which differed from some of
the observations previously recorded. Among other observations was
one as to the time of the first micturition after birth. Forty-five
cases cover the series. It was found that the time varied greatly.
In fifteen it occurred simultaneously with birth; in ten, in less
than four hours; in eight, in from four to eight hours; while the re-
mainder ranged between eight and eighteen hours after birth. In
but two cases was it longer than fourteen hours. Without going
into detail as to other studies made of the urine in young children, it
was found that the specific gravity, the frequency of urination, and
the amount of urine passed were subject to wide variations within
normal limits. These various features depended upon whether the
child was breast-fed or bottle-fed, whether it was a girl or a boy, and
whether, if breast-fed, the mother had a scanty or a free flow of
milk. The bottle-fed always passed more urine than the breast-fed.
The quantity of urine is also influenced by the clothing worn and by
the season of the year.
Normal Variations. — Normal variations are therefore necessarily
within very wide limits. One child will pass its urine every thirty
minutes when awake ; others, of equal health and age, will retain it
for three hours. Before the child takes much fluid, particularly in
the first days of life, from two to five ounces is probably passed in
twenty-four hours with a specific gravity of 1.005 to i.oio. Infants
urinating very frequently are apt to develop into bed-wetters in later
life, probably owing to the undeveloped condition of the bladder, the
size of that viscus remaining small. Other than this, very frequent
urination with an absence of signs of illness is of no significance in the
young. After the feeding is established, the specific gravity will
range from 1.003 to 1.012 from the second week to the second year.
A baby nine months old will pass an average of about twelve ounces
of urine in twenty-four hours. When six years of age, from sixteen
to twenty-five ounces will be passed with a specific gravity under
1. 01 5. From this age until puberty both the quantity and specific
335
336
THE URINE
gravity gradually increase, the usual range in specific gravity being
from i.oio to 1.020.
Method of Collecting Urine. — The collection of the amount voided
in twenty-four hours in children of the "runabout" age is difficult,
and in young infants well nigh impossible. For accurate work
the specimen should be obtained by the catheter. When for any
reason this is not possible, there are various devices for collecting the
urine, any one of which may be tried. The tying on of a wide-
mouthed bottle or a condom in boys, fastening it with adhesive strips
to the body, is often successful. Absorbent cotton into which the
child urinates, the urine being expressed from it into a bottle, may
be used for either boys or girls, as may also the Chapin collector
(Fig. 38). The chief disadvantage of any of
these measures is the certainty of contamina-
tion. The urine so collected may answer for
an examination for albumin, sugar, or the renal
elements, but is useless for a bacterial study.
From the second to the third year conti-
nence at night is usually established. If in-
continence continues after the third year, the
case should be looked upon as abnormal and
receive treatment accordingly. (See Inconti-
nence of Urine, page 338.)
DIFFICULT AND PAINFUL URINATION
Painful urination is of frequent occurrence
in infants and "runabout" children. It may
be due to irritation at the urethral outlet fol-
lowing injury, or to scalding from acid urine,
but more frequently the irritation is due to
lack of cleanliness of the parts, which remain
moistened, and inflammation results.
In two cases I have found calculi in the
urethra. Both were in boys about five years
of age. By far the greater number of patients
who suffer from difficult micturition are boys, and it is due to phimo-
sis with adhesions and retained smegma. Attention to the external
genitals in the matter of cleanliness, the operation of circumcision,
or the relief of adhesions by slitting the foreskin and freeing the
glans, promptly relieves the condition.
Fig. 3S. — Chapin Urine
Collector.
RETENTION AND SUPPRESSION OF URINE
In using the above terms with reference to diseases of the urinary
organs it is well to appreciate their significance. By suppression is
meant a condition of anuria in which no urine is passed into the blad-
der, that viscus being found empty on catheterization. Inretention,
RETENTION AND SUPPRESSION OF URINE 337
the urine is secreted by the kidneys and passed into the bladder but is
not voided. When the urine is not voided, we must always ascertain
whether there is suppression or retention. If there is retention, it
can usually be discovered by palpation and percussion. In fat chil-
dren a positive diagnosis may be impossible by this means. In any
event, when in doubt, a catheter should be emploved. For infants
under one year of age a soft-rubber catheter, No. 4 or 5 American,
should be used. If suppression is diagnosed and treatment by diu-
retics instituted, when there is simple retention, no little trouble will
result, as I have occasionally seen.
Suppression of the urine may persist for hours without any grave
pathologic condition of the kidneys. Chilling of the skin surface
may be a cause. In acute gastro-intestinal disorders with frequent
vomiting and watery stools there may be suppression for twenty-
four hours. The secretion is re-estabUshed when there is again an
available fluid to be added to the circulation from the digestive tract.
If the suppression is due to causes of a grave nature, such as acute
nephritis, there will usually be signs of trouble other than the sup-
pression, such as vomiting, fever, and edema.
Retention may result from an injury to the urethra, or in girls
from vaginitis or in boys from phimosis. Impacted stone in the
urethra was a cause in two boys seen by me. Fortunately in each
case the stone was located near, the meatus and readily removed.
The bladder of the infant and young child is very readily infected
and care should be exercised to have the catheter sterile before it
is used.
Treatment. — The immediate relief of retention is by catheteriza-
tion. Further treatment consists in the correction of the exciting
cause. If a catheter is not at hand, the application of a hot stupe
over the lower portion of the abdomen and the genitals may be suf-
ficient to stimulate urination.
Colon Flushing. — Colon flushing in suppression of the urine is one
of the most effective measures of relieving this very urgent condition.
The apparatus required and the methods employed will be found on
page 207. If the temperature of the patient is not above 102° F.,
the normal salt solution, at a temperature of 110° F.,is advised. I
have alwavs found the flushing more effective when this degree of heat
was used. One pint is introduced, for a child three years of age. In
children of one year or under, from four to eight ounces is all that will
be retained. It must not be repeated, however, oftener than once
in six or eight hours, as the colon of a child soon becomes intolerant
of the injections and but little will be retained. Repeatedly, after
the first injection, the kidneys have resumed activity when all other
means have failed. It has been particularly useful in cases following
or accompanying the exanthemata, where there was an acute ne-
phritis with greatly diminished secretion of the urine.
338 THE URINE
INCONTINENCE OF THE URINE ; BED-WETTING ; ENURESIS
The involuntary discharge of urine is normal in the young infant.
Urination becomes a voluntary function at a later age, the time de-
pending largely upon the child's training. In most children, with the
right kind of management, it may be controlled during waking hours
by the tenth month. During sleep, it continues to a later period,
and while in many cases it may be under perfect control at the com-
pletion of the second year, I do not regard the loss of control as
abnormal until the third year is completed. If during the second
year the child shows a tendency to frequent urination and involuntary
passage of urine during waking hours, w^ith habitual incontinence at
night, it is my custom to advise preventive measures.
In some of these children the urine is very acid and of a high spe-
cific gravity — 1.020 or over. In such cases a reduction of the
quantity of the highly nitrogenous food-stuffs in the diet, especially
meat and eggs, is often followed by improvement — the eggs and red
meat being given alternately not oftener than every second day.
Where the urine is normal, the quantity of fluids given during the
twenty-four hours is reduced from 25 to 50 percent and more solid
nourishment substituted.
When the incontinence persists during waking hours at the com-
pletion of the second year, or during sleep at the completion of the
third year, the condition is regarded as abnormal and the child placed
under treatment.
In assuming the care of a child w^th incontinence our first step is
to discover the cause of the trouble. With this object in view the
patient is examined with the idea of discovering any peripheral ab-
normality which may have a bearing on the disorder. Thus the
incontinence may be due to a vaginitis or to an adherent clitoris in
girls, or to phimosis in boys; it may be due to thread-worms in the
rectum, to constipation, to stone in the bladder, to cystitis — a very
rare condition, and to hyperacidity of the urine — a very common
one. The diet also may play a part. The use of highly nitrogenous
food in large amounts, or a diet rich in sugar may lead to changes in
the urine sufficient to cause the trouble. The presence of adenoid
growths in the nasopharyngeal vault is supposed by some writers to
cause enuresis. As a result of the diurnal and nocturnal inconti-
nence, the bladder may never have developed and its capacity may
be greatly reduced. Obviously, when such is the case, incontinence
will be noted both day and night.
After all possible dietetic and peripheral causes have been elimi-
nated, about 90 percent of the cases remain. These are due to a
neurosis, and are not dependent upon any discoverable pathologic
condition. There is a lack of development, a weakness of the vesical
INCONTINENCE OF URINE; BED-WETTING; ENURESIS 339
sphincter, and a lack of coordination of those portions of the sympa-
thetic nervous system which control micturition.
Treatment. — If due to peripheral causes they must be corrected
and the general physical condition of the child improved, although
in my experience the deUcate and chronically ailing are not the chil-
dren who are the greatest sufferers. By far the larger number of my
patients have been well-nourished children who were otherwise nor-
mal. Long-continued incontinence does not appear to affect the gen-
eral health. When well established, the condition, untreated, usually
continues until the child is eight or ten years of age. I have known
of a few cases which persisted until puberty.
If no improvement follows the removal of all possible dietetic
and peripheral causes, we must assume that we have an idiopathic
incontinence to deal with. If the case is of several months' or years*
standing, with nightly incontinence, once, twice, or three times, we
must acquaint the mother with the fact that prolonged treatment
will in all probability be required, and that unless her active and
continued cooperation is assured, the treatment of the case will not
be undertaken.
Illusirahve Cases. — To show how untiring must be our efforts,
a recital of an early experience with twelve inveterate bed-wetters
may not be without interest. Several years ago, while resident phy-
sician at the New York Infant Asylum, twelve patients, nine boys
and three girls, ranging in age from six to ten years, were selected for
treatment. All were in fair health. No local cause for the enuresis
could be discovered in any of them. They had been given the
usual treatment with strychnin, belladonna, and other drugs without
improvement. They had always been bed-wetters. All wet the bed
two or three times during the night, and three suffered from daily
incontinence as well. The oldest, a boy of ten, with incontinence
by day and night, pronounced incurable, had been returned to us
from the West, where he had been sent by The Children's Aid Society.
The patients were put to bed at seven o'clock and wakened at
ten, to urinate. The medication suggested below was used. Symp-
toms of atropin poisoning occurred in three in the form of a typical
belladonna blush and excitement. After six weeks of treatment
there was slight improvement in four. One or two nights a week
would be passed without bed-wetting. At the end of the third
month the lapses were but once or twice a week. Seven were prac-
tically well at the end of the fifth month, rarely wetting the bed. The
treatment was continued two months longer, when the dose was
reduced one-half, again continued for two months, and then stopped,
and nine months after final discontinuance there had been no return.
The remaining five cases, all over six years of age and including all the
girls, showed but shght improvement after the fifth month of treat-
ment, the incontinence being of almost nightly occurrence. During
340 THE URINE
the next three months the improvement was gradual, and at the end
of the eighth month incontinence occurred not oftener than twice a
week, and during the tenth month it was only occasional. The dose
was reduced one-half, and after one year of continuous treatment
there was no return of the trouble. The atropin was stopped, and
six months later the cure was apparently complete.
These cases need not cause discouragement, as they were invet-
•erates, all over six years old, and the oldest ten. They had always
wet the bed and had resisted all previous treatment.
Frequently a treatment of from four to six weeks or even for a
shorter time effects a cure. The child receives three meals daily.
The breakfast and dinner correspond to the age of the child, but one
should emphasize the fact that red meat is to be given but once during
the twenty-four hours. The supper, which should not be later than
six o'clock, I designate a " dry supper." It may consist of any cereal,
such as rice, hominy, farina, or wheatena, served with butter and sugar.
If this is not well taken, a small quantity of both sugar and milk may be
added. Permissible articles for the evening meals in addition to the
above are: ice-cream, milk-toast, blanc-mange, raw fruit, jelly,
stewed fruit, bread and butter. Meat, eggs, or heavy foods of any
kind should not be given at night. At four o'clock in the afternoon
the child is given as much water as he wishes, but no fluids after this
time are allowed, other than a little milk on the cereal. The abstinence
from all fluids after 4 p. m. will at first be a hardship for some children,
and they may be allowed a small quantity — three or four ounces of
milk or water — with the evening meal; but this quantity should
gradually be diminished until at the end of a week it will not be
missed.
The child should be as lightly covered at night as comfort will
permit. There is less tendency to incontinence if the child rests on
his side or stomach. Sleep in this position should be encouraged.
In inveterates, where every possible aid is brought into use, I have
used the knotted towel as a means of keeping the child off his back.
A knot is tied in the middle of the towel. It is then passed around
the child so that the knot will rest on the back. If it is long enough,
the ends of the towel may be pinned together over the abdomen like
an abdominal binder. When the child attempts to rest on the back
the knot causes discomfort and the position is changed. At 10 or
II o'clock, when the person in charge retires, the child should be
taken up to urinate.
Drugs. — Without a strict observation of the above measures,
particularly those referring to diet and the abstinence from water after
4 p. M., drugs are of no value, whatever their method of administra-
tion. With the above suggestions carried out, we have one remedy
which is of great value, and that is belladonna. For convenience of
administration I prefer the alkaloid, atropin. To get the full benefit
INCONTINENCE OF URINE; BED- WETTING; ENURESIS 34I
of the treatment in severe cases it must be pushed till we obtain the
physiologic effect, as shown by a slight dilatation of the pupils. Be-
fore beginning the treatment it is well to advise mothers that a red-
ness of the skin need cause no alarm, but that when it is noticed they
should discontinue the drug until further instructions are given.
The atropin is administered as follows: One grain is added to an
ounce of water; one ounce of water contains approximately 500
drops, so that one drop of the atropin solution would contain ap-
proximately 5I0 grain of the drug. The mother is given a chart
containing the directions for administration, which for a child five
years of age are as follows :
1st day 4 p. M., 0 drop 7 p. m., 1 drop
2d " " 1 " " 2 drops
3d " " 2 drops " 2 "
4th " " 2 " " 3 "
5th " " 3 " " 3 "
6th " " 3 " " 4 "
7th " " 4 " " 4 "
8th " " 5 " " 5 "
The child is given one drop daily at 4 and 7 p. m. for every year
of its age. Thus, for a child three years old the dosage should not
be greater than three drops, twice daily ; for a child six years old not
over six drops, twice daily, would be given. It may be well, if the
case is not under close observation, to make a more gradual increase
in the dosage so as to avoid the possibility of unpleasant physio-
logic effects.
It is never advisable to exceed these doses even in older children,
for the reason that they are sufficient to control the enuresis ; and
the dilated pupils and belladonna blush which follow the increased
doses show that such doses are unnecessary.
The tolerance of atropin varies considerably, although children
usually bear it very well. Now and then a child is treated who
cannot take more than two drops (2^0 grain) daily. To one boy
eight years of age but 2^0 grain could be given twice daily. Pro-
nounced benefit, ordinarily, will not be observed during the first
week or two of treatment. If the child suffers from incontinence
while awake, this will first be cured. The improvement in nocturnal
incontinence is more gradual and may be considerably delayed.
Thus, no improvement whatever may be seen for two or three weeks.
In the cases cited above it will be noticed that, in three, no improve-
ment occurred until the sixth week. In the average case the im-
provement is gradual. Instead of wetting the bed every night there
will be nights at short intervals when there will be very slight
incontinence, or none at all.
Usually after a few weeks' treatment the incontinence entirely
ceases. The mistake frequently made is to stop the atropin at this
342 THE URINE
point. When this is done there is usually an immediate return of
the trouble. The full treatment should be continued until the child
has ceased wetting the bed for at least two weeks, when the daily
amount of atropin should be reduced one-half and kept at this point
for six weeks. If at the end of tw^o months from beginning treat-
ment there is no incontinence, the drug may be discontinued, but
the dietetic regulations, particularly the "dry supper," should be
continued for three months longer. It must be remembered that
the element of habit, which has become established, is hard to
overcome, even after the neurosis and the sphincter weakness have
been corrected.
Strychnin and tincture of cantharides have been advocated by
pediatric writers. In weak, poorly nourished children strychnin
may be added to the iron or oil tonics, and, as a tonic, be of
service in improving the general condition of the patient, and
indirectly be an aid in the treatment of the enuresis. When in-
continence occurs only during the day, the dietetic regulations are
the same, with the exception that the fluids allowed need not be cur-
tailed unless the quantity is excessive. The dosage of atropin is the
same, but the time of administration should be changed to after
breakfast and after luncheon, instead of at 4 and 7 p. m. In addition
to the atropin, strychnin should always be given in cases of inconti-
nence by day, as a lack of development or a relaxation of the sphincter
is more of a factor with them than is failure of nerve coordination.
A fact to be taken into consideration in making a prognosis as to
the probable duration of the treatment in a given case is the size of
the bladder, since a child who has suffered from incontinence both
by day and night may have a small and contracted bladder because of
lack of development from disuse. In one of my cases, in a girl five
years of age, the bladder had a capacity of but one ounce. The
most reliable means of determining the size of a bladder is by meas-
uring the amount of sterile water which can be introduced through a
catheter.
ALBUMINURIA
Albuminuria may be either transient, cyclic, febrile, or paroxysmal,
these terms indicating the different conditions under which albu-
min is found in the urine. Aside from the albumin, there may
be no indication of organic kidney disease, either clinically or micro-
scopically. In children the presence of albumin without other signs
of trouble is of much greater import than is a similar condition in
adults. The absence of proof of a kidney lesion does not mean that
such a process may not exist. My own experience with cases of so-
called functional albuminuria has not been a particularly pleasant
one.
More or less persistent albuminuria, regardless of its association
with muscular exertion or mental excitement, means that a tempo-
ACUTE .NEPHRITIS
343
rary change is taking place in the renal epithelium. Frequent repe-
tition of such processes readily leads to organic changes, and I am
always disturbed by the presence of albumin, as I consider the con-
dition one not to be lightly regarded. One of my cases, now under
treatment, shows a trace of albumin after eating an egg, and in three
of my cases, a diet rich in meat and eggs will invariably be followed
by albuminuria.
Treatment. — The management of these cases involves the dis-
covery and removal of the source of the irritation. If caused bv
emotion, exertion, or diet, a correction of the child's daily habits
should be made along rational lines. I require these patients to be
given a diet free from eggs, while red meat is allowed not oftener
than twice a week. They are to avoid sudden exposure to cold, to
wear flannel next to the skin nine months in the year, and light-
weight silk-and-wool undergarments during the hot months. They
are not allowed to indulge in hard play. Baths below 80° F. are
not to be given them. Ocean bathing is prohibited. A salt bath
(page 31), followed by a brisk friction with a coarse towel, is given
at bedtime. The activity of the skin is thus insured. The bowels
are kept open by the free use of fruits and the malted foods. If a
laxative is required, salines are preferred. The case should be
under observation, the above precautions observed, and the urine
examined at intervals of two or three months for one year after the
last negative examination for albumin.
ACUTE NEPHRITIS
Nephritis, in common with many other ailments of children, may
be either mild or severe. It may be so severe as to cause death in a
few hours or so mild as to pass unrecognized. The disease is rarely
primary, being usually due to some systemic infection. The treat-
ment of the severer forms of nephritis is often open to the most em-
phatic criticism, reflecting as it does the present methods of the
schools, in their advocacy of forced, indiscriminate water-drinking,
the exclusive milk diet, and the more or less indiscriminate use of
diuretic drugs. Every one of these measures is capable of, and has
been productive of, no little harm. Too great emphasis has been
placed upon forcing the kidneys to act and too little upon the neces-
sity of reHeving them of the work for which they are temporarily
incapacitated. The advocacy of drinking large amounts of water
when the kidneys, distended with blood and the tubules obstructed,
are secreting but very little, does nothing but harm. Under similar
conditions, heart stimulants, such as digitaUs, which forces more
blood into the kidneys, necessarily make a bad condition w^orse.
Treatment of Mild Cases.— In treating nephritis, there are several
factors to be kept in mind. Because a case is mild it should never
be given scant attention. Nephritis in a child may be most insidi-
344 THE URINE
ous in its course. The mildest case, while not treated in all respects
like a more severe one, should be given every possible attention as to
rest in bed and diet, for through neglect, even for a very few hours,
it may become most severe.
A child with nephritis must be kept in bed with the temperature
of the room at about 70° F. He should be protected from drafts of
cold air. Silk, a mixture of silk and wool, or flannel should be worn
next to the skin.
The nutrition of the patient is to be maintained by food which
will not add to the existing trouble. We are told in the books that
nitrogenous food, such as meat and eggs, is to be avoided in order to
relieve the kidneys from the work of the secretion of urea and cre-
atinin, and yet often we are advised in the very next line to give a full
milk diet, which in a child from five to ten years of age means from
two and one-half to three quarts daily, which, it will be remembered,
contains 4 percent of nitrogenous food proteid. A diet necessitating
that large amount of nitrogenous waste (by-products) will have to be
excreted by the kidneys. In order to maintain the nutrition of the
patient, proteid is necessary, and may be supplied by the use of a
moderate amount of milk. For a child under five years of age, from
sixteen to twenty ounces of full milk should be given daily — never
more than twenty ounces. This is diluted with equal parts of
cereal gruel. No. i or 2, wdth the addition of one teaspoonful of
sugar (see formulary, page 124), and given in quantities of from six
to ten ounces at four-hour inter\^als. This supplies all the nourish-
ment necessary for a patient of this age. In order that the diet may
not become monotonous to the child and cause loss of appetite, as
is almost always the case when full milk is used, the taste of the food
may be changed by the use of cereal gruels of different kinds.
Broths and beef extracts are not given because of their creatinin
content. Zwieback and butter, stale bread and butter, prune- juice,
thin apple sauce, and orange-juice may be given in order to improve
the digestion and add variety to the diet. Inasmuch as milk cannot
be taken at the same time as fruit by many patients, it may be given
between meals or wdth a plain meal gruel.
A patient with nephritis, no matter how mild, should have two
movements daily. These should be rather loose. The use of the
fruit-juices may be sufficient to keep the bowels relaxed. If a laxa-
tive is necessary, citrate of magnesia or, in very young children and
infants, milk of magnesia may be given in such doses and at such
intervals — either of twelve to twenty-four hours — as may be neces-
sary to produce the desired results. Twenty-four hours should not
pass without an evacuation of the bowels. The patient should
always have an enema at bedtime, if no passage has taken place dur-
ing the preceding twenty-four hours.
ACUTE NEPHRITIS 345
There should be a warm sponge-bath daily, the body being
sponged and dried in sections under a flannel blanket.
Prophylaxis. — If during scarlet fever or any of the infectious dis-
eases the physician takes the precaution of having nitric acid and a
few test-tubes at the home of the patient, so that the urine may be
tested for albumin at each visit, with a reasonably frequent micro-
scopic examination at his office, a nephritis may be detected before
the more active clinical signs of the disease appear, and thus by plac-
ing the patient promptly under the above management, usuall}- but
little trouble will be experienced. In fact, in a majority of the
cases the above suggestions are all that are necessary to carry the
patient safely through an attack, if the kidney involvement is detected
early and if diuretic drugs are omitted from the treatment. The use
of additional measures for the more severe cases will depend, to a
considerable extent, upon the individual case.
Treatment of Severe Cases. — When there is fever with partial
suppression of the urine, only one-half the usual quantity being
passed and that loaded with albumin, blood, and casts, with per-
haps beginning edema, colon flushings (page 496) with a normal salt
solution at a temperature of 110° F. are to be used. The flushings
have the effect of increasing the functional activity of the kidneys.
For a child from five to ten years of age, one pint of the warm saline
solution may be thrown into the colon. An effort should be made to
have the child retain it by having him rest on his left side with the
buttocks elevated on a pillow. In young children from eight to
twelve ounces may be used, and in infants under nine months, from
four to six ounces is all that we may hope to have retained. The
flushings should not be repeated oftener than at twelve-hour inter-
vals, unless the condition is urgent, as an intolerance of the parts is
readily brought about by too frequent manipulations.
If there is a hot, dry skin with a tendency for the temperature to
remain above 102° F., tincture of aconite is given in small doses.
For a child three years of age, one-half drop is given at two-hour
intervals. Older children may be given one drop at a dose. It is
rarely wise to increase it above two drops at two-hour intervals even
in children above ten years of age. Only sufficient should be given
to produce a slight diaphoresis, for by keeping the skin constantly
moist the blood-vessels of the kidneys are relieved of the tension to
which they have been subjected.
In the severer forms with edema or anasarca, cases in which but
two or three ounces of urine are passed daily, more active measures
will be required. In these urgent cases the diet should consist tem-
porarily of thin gruels of barley, granum, or rice (No. i), with sugar
added to make them more palatable, and diluted fruit- juices given
between the feedings. In a carbohydrate diet there are no by-
products irritating to the kidney. Water should be given scantily.
346 THE URINE
sufficient fluids being given in the food. Active measures to increase
the diaphoresis and thus reUeve the kidneys must be instituted.
The best means of doing this is by the use of hot colon flushings, hot
packs, and hot baths. In these cases it is by attempts at forcing
the kidneys, by the use of digitahs and the alkaUne diuretics, that we
do an immense amount of harm. Digitahs drives more blood into
the kidneys and thus increases the congestion. The alkaline diuretics
disturb the stomach, which is already showing signs of food intoler-
ance. Colon flushings at i io° F. are now to be used every six hours.
This is probablv one of the most valuable means we possess for re-
lieving the congestion of the kidney and inducing a flow of the urine.
Heat, either drv or moist, is to be brought immediately into use
in order to stimulate the skin to vigorous action. Both dry heat and
moist heat have their advocates. Placing a child in a warm bath at
105° F., keeping him there for a few minutes,
drying rapidly, and immediately putting him
into bed, surrounded by hot-water bottles, will
usually produce diaphoresis. A thermometer
should be placed under the bed-clothing so
that excessive heat may readily be detected.
I have seen pronounced weakness produced
by excessive heat used for such a purpose.
The child should not be allowed to rest in a
temperature higher than 120° F., and this
should not continue for over ten minutes, A
temperature of 105° F. or 110° F, may be
maintained for an hour if necessary. If the
packs are used, they may be repeated once
^'"^tus'^f^th'e k'ilmI^r ^^ ^^^ hours. The disadvantages of a hot
Croup Kettle. bath are duc to the fact that it necessitates
considerable handling, which to some pa-
tients is a cause of no Uttle excitement. In such cases, dry heat
may be substituted. The patient is warmly clad in flannels and
hot-water bottles are placed near him. This mav be sufficient to
induce perspiration, A device which I use consists of a funnel
attached to a one-inch brass pipe which is bent in the middle to a
right angle and which conducts the warm air under the bed-clothing.
The heat is generated by a kerosene lamp, over the top of which an
inverted funnel is placed at a sufficient distance to allow combustion
to take place. The Kilmer croup kettle has an appliance which
may be used for this purpose (Fig. 39).
While a free secretion of urine is desired in these cases, w^e must
not be content with that alone. Uremia may occur even while the
normal amount of urine is being passed. A quantitative test for
urea should be made in all severe cases in order to determine the
amount excreted. Normal human urine contains, roughly speaking,
ACUTE NEPHRITIS 34
2 percent of urea, which occasionally in health rises to 3 per cent.
Approximately 0.5 gram of urea is excreted per kilogram of body-
weight. The proportion in children is relatively higher.^
Treatment of Uremic Convulsions.— Vomiting is one of the first
symptoms of uremia. When it occurs, all food should be temporarily
withheld from the stomach and nutrient enemata given by rectum.
Completely peptonized skimmed milk is our best means of nutrition,
from four to twelve ounces being given every four to six hours. It
is best to give large quantities at long intervals — every six hours is
best, as the manipulations with the tube have a tendency to produce
intolerance on the part of the gut. The tube should be introduced
at least eight inches into the bowel and the solution used should be
lukewarm. A temperature of 95° or 100° F. will best be retained.
In addition to the use of colon flushings and external heat, uremic
convulsions should be controlled with chloroform or the rectal ad-
ministration of the bromids or chloral. For a child under three years
of age, from two to three grains of chloral may be given with eight
grains of bromid of soda. After the third year, three grains of
chloral may be used with from eight to fifteen grains of bromid
of soda. It is best retained when given in at least four ounces of
mucilage of acacia or skimmed milk, the enema being repeated in
four or six hours.
When heart stimulants are required, tincture of strophanthus is
usually given — from one to two drops at two-hour intervals to a
child under three years of age. After this age, from two to three
drops may be given. Digitalis is sometimes used as a heart stimulant
during convalescence, after the secretion of the urine has been estab-
lished.
Convalescence. — Convalescence is often tedious in these cases.
The child should not be allowed to be out of bed until albumin has
disappeared from the urine. For at least six months after an attack,
the urine should be examined weekly. Light-weight woolens should
be worn next to the skin during the entire year and every effort made
'R. Bradford, in AUbutt's "System of Medicine" :
Amount of Urea Excreted on the Basis of 0.5 Gram per Kilogram.
1 vear ^ ^"^^ ^'^^ "^-^45 gms. in 24 hrs.
' y^""' \Girls 8.24* 4.12 gms. in 24 hrs.
3 years 1 5?^^ ^"^-^"^ "O^ g"is. in 24 hrs.
^ years ^ Girls 13.60* 6.80 gms. in 24 hrs
7 years ^ ^"^'^ ^2.44 11.22 gms. in 24 hrs.
years ^ ^^^j^ 21.78* 10.89 gms. in 24 hrs
10 years f ^T o^-.i " ^^'^^ gms. in 24 hrs.
^ \ Girls 29.0/* 14.535 gms. in 24 hrs.
13 years ( ^"f 1??^^ 20.02 gms. in 24 hrs.
\ Girls 41.36* 20.68 gms. in 24 hrs.
16 years ( ^^f 56.09 28.045 gms. in 24 hrs.
■^ \ Girls 51.24* 25.62 gms. in 24 hrs.
* Figures of Boas, quoted from Holt.
348 THE URINE
to protect the patient from sudden exposure to the influence of cold
air. With the advent of future illness with fever, even though it does
not occur for a year or two afterward, unusual precautions should be
taken to protect the child, in view of a possible reinvolvement of the
kidneys with, possibly, a resulting chronic nephritis. Meat and eggs
should be given scantily for a year after an attack. Exercise calling
for great muscular effort should not be allowed for a considerable time,
at least for a year after all trace of the nephritis has disappeared. I
advise that, when possible, the winter after an acute attack be spent
in a warm climate, such as that of Florida or Lower California.
Scarlatinal Nephritis. — A form of acute nephritis which deserves
particular attention occurs early in malignant scarlet fever. The
onset is very abrupt. But little urine is passed, and this is filled
with albumin and casts and blood. In a recent case complete sup-
pression occurred without previous warning and the child died in
thirty-six hours, the duration of the entire illness being but seventy-
two hours. There was no edema. The child became comatose and
died from the uremia and the intense scarlatinal poisoning. In these
cases repeated hot baths and packs, 105° to 110° F., should be used
in spite of the high temperature which is usually present. Frequent
hot colon flushings, 110° F., should also be given. Heart stimulants
hypodermatically may be of value. The prognosis in these cases
is very unfavorable.
CHRONIC DIFFUSE NEPHRITIS
This disease is rarely seen in children under three years of age,
and it is almost invariably the result of an acute process which ran its
course unrecognized, or of faulty management following an acute
nephritis. The following history is quite a common one : A patient
who came under my care three years ago with chronic nephritis gave
a history of having had three distinct acute attacks during the pre-
vious four years, with inter^^als of apparent health. The urine had
not been examined during these intervals nor had she had the ad-
vantages of proper treatment.
Treatment. — The management of chronic diffuse nephritis in
children resolves itself into care in four respects: diet, cHmate, baths,
and exercise.
If the patient is confined to the bed, the diet should be the same
as suggested under acute nephritis. One quart of milk may be given
daily. If the child is up and about, meat may be given once every
second day. Eggs should be excluded. In other respects the diet
should be simple, as outlined for well children (page 128), this being
ample for nutrition.
The child should receive one warm bath — 95° to 100° F. — daily,
followed by a brisk friction with a dry towel.
An outdoor life is of decided advantage; exertion, however,
GLYCOSURIA
349
should not be allowed to the point of fatigue. Contests or stress of
any kind, mental or physical, should not be permitted.
If possible, the child should spend the colder months in a climate
which is not subject to sudden or wide variations in temperature.
The climate furnished by Florida or Lower California is advocated
when the parents are financially able to give the patient the benefit
of it. If, however, he must be kept in his home, which does not offer
the advantages of an equable climate, great care should be exercised
in preventing sudden chilling of the skin surface. Woolens should
be worn next to the skin at all seasons of the year. Frequent exami-
nations of the urine should be made, not only for albumin and casts,
but for urea as well. Sudden attacks of uremia may occur even
while the patient is passing an excessive amount of urine.
Chronic interstitial nephritis is very rare in children. I have seen
one case in a patient ten years of age who had been ill two years. He
was passing a large daily amount of urine — 60 to 90 ounces — an ex-
amination of which showed a specific gravity of 1.002. There was
but a trace of albumin. The boy died in a few weeks of acute uremia.
GLYCOSURIA
Temporary glycosuria or dietetic glycosuria is of frequent
occurrence and is of little significance. It usually means that
more sugar is being taken than can be cared for by the economy,
and with a discontinuance of its excessive use the sugar disap-
pears from the urine.
Illustrative Cases. — In a series of observations made several
years ago at the Country Branch of the New York Infant Asylum,
ten children were selected for high-sugar feeding, 10 percent sugar
mixtures being given to those under one year of age. Every
case showed glycosuria after twenty-four hours of the high-sugar
administration.
Two most interesting cases of persistent glycosuria without
any other manifestation of illness have been under my observa-
tion for the past six years. That sugar existed in the urine was
discovered by accident. How long it may have been present, we
have no means of knowing. The mother, an unusuallv careful
woman, conceived the idea that it would be wise to have the
urine of all her four children examined. It was accordingly sent
to me, and greatly to my surprise I found that two specimens,
one from a boy of four years, the other from his brother of six, con-
tained a large amount of sugar— 3 and 3.5 percent respectively. A
careful examination was at once made of both patients, and nothing
abnormal discovered. The children were strong, there was no
unusual thirst and no polyuria, and, further, the examination
of the urine failed to reveal the presence of either acetone or
diacetic acid. They were placed on a rigid anti-diabetic diet (page
350
THE URINE
351), which reduced the sugar to 1.5 and 2 percent respectively.
During the six years that have since intervened, the boys have made
satisfactory physical and mental progress ; they have attended school
regularly except when prevented by the usual ailments of childhood.
Both have undergone operation for adenoids and enlarged tonsils
under ether anesthesia, with no more than the usual discomfort.
They have made normal increase in stature, weight, and strength,
and are perfectly normal in appearance. During these years monthly
examinations have been made of the urine. There has never been
less than 1.5 percent of sugar in either, and during the past eighteen
months it has rarely been below 3 percent or above 6 percent, and
that in spite of the most careful diet. There never has been polyuria
or extreme thirst. The children have been seen by several consult-
ants in New York city and have been under the treatment of
three well-known specialists in Germany. Recently acetone has
been found in the urine of one of the children. Probably every va-
riety of treatment which might be expected to exert an influence on
the sugar production has been tried for protracted periods without
a particle of influence in reducing it. Indiscretions in diet increase
the sugar, otherwise it ranges as stated above. None of the physi-
cians here or abroad who have treated the boys has seen similar cases.
They are cited in detail and are of much interest as showing the in-
efificiency of medication in glycosuria and the effects of diet, and,
furthermore, they present a clinical picture which is most unusual.
It has been suggested that the glycosuria may be due to some
persistent and unusual toxemia from intestinal sources, and the
cases are now being studied on that theory.
DIABETES INSIPIDUS— POLYURIA
Persistent polyuria — diabetes insipidus — is rare in children. I
have personally known of but one case. It had been but little influ-
enced by six weeks' treatment at the time it passed from under obser-
vation. Temporary or transient polyuria is of occasional occurrence
and appears to be entirely of nervous origin. It is usually seen in
nervous girls of hysterical tendencies. It is most apt to develop at
the close of the school year, when a child is considerably reduced or
somewhat excited in anticipation of undergoing examinations. The
patient is thirsty, drinks quantities of fluid, and passes a great deal
of pale urine of low specific gravity. Full doses of bromid of soda —
ten grains three times daily — may temporarily reHeve these condi-
tions. In all the cases which I have seen, the polyuria ceased in a
short time, with the cessation of school duties and a change of en-
vironment.
DIABETES MELLITUS
But little of promise is to be offered in the management of diabetes
mellitus in children. It is a particularly fatal disease. I have treated
VESICAL CALCULUS. CYSTITIS 35I
five cases, and all have terminated fatally. This is similar to the
experience of all observers. The youngest patient was three, the
oldest nine years of age. The manifestations of the disease were the
same in all. There were excessive thirst, rapid loss in weight, the
passage of large quantities of urine containing varying amounts of
sugar, and a dry, roughened skin. Not one of my patients lived a
year after the commencement of the disease. Death usually takes
place in less than six months.
The patients were treated by limiting the amount of fluid taken,
by restricting the diet, and by using the opium derivatives and
arsenic to the point of physiologic effect — all without the slightest
benefit. The sugar output was reduced, but the patients showed
not even temporary improvement as to their general condition.
Children with diabetes mellitus usually die from exhaustion or from
some intercurrent disease like pneumonia. Uremia is of less frequent
occurrence in children than in adults.
Diet. — The following are permissible articles of diet for a child ill
with diabetes : Soup and broths made from meat, fresh and salt fish,
shell-fish occasionally, egg, fowl, and game, smoked meats, sweet-
bread, cheese, spinach, celery, lettuce, cucumbers, cranberries,
radishes, string beans, asparagus, squash, cabbage, egg-plant, to-
matoes, onions, turnips, mushrooms, gelatin jellies sweetened with
saccharin, butter, cream, olive oil, cod-liver oil, lemon, grape-fruit,
sour apples, blackberries, raspberries, watermelon. Nuts of all kinds
may be eaten. Only bread and biscuits made from gluten flour should
be used. It is impossible to procure a starch-free gluten flour ; the
flour, however, should not contain more than 20 percent of starch.
VESICAL CALCULUS-STONE IN THE BLADDER
Stone in the bladder is rarely seen in children under ten years of
age. Two cases only have come under my obser\^ation. The pa-
tients were boys aged respectively five and seven years. The treat-
ment of the condition is entirely surgical.
CYSTITIS
Cystitis is an uncommon affection in children and I have never
seen a case in a boy. In girls, however, it is of occasional occurrence,
and is usually due to an infection of the bladder with the colon bacillus.
There is little or no pain attending urination, but there are
frequent calls to urination, of the most urgent character. All of my
cases of cystitis have suffered from incontinence of urine, during both
waking and sleeping hours. We are sometimes told by the mother
that the child asked to be taken to the toilet, but passed the urine
before reaching it. Inability voluntarily to control the urine during
the day, extending over a considerable period of time, points strongly
to bladder involvement, either to stone, which is exceedingly rare in
352
THE URINE
children, or to cystitis. An examination of the urine usually clears
up the diagnosis so far as the cystitis is concerned.
Treatment. — The treatment is largely through internal medication,
and is not particularly promising as regards the promptness of a cure.
Irrigation of the bladder may be attempted. It has been of very little
service in my hands. Bladder-washing is carried on with no httle
difficulty and annoyance and usually with unsatisfactory results.
My best success has been by the use of urotropin — three grains, three
times daily to a child three years of age. In cases due to the colon
bacillus it is well to alternate the urotropin with citrate of potash,
three grains of which are given three times daily, the urotropin being
given alone for five days, followed by the citrate of potash for the same
time, alternating thus, when necessary, until a cure is effected.
ACUTE PYELITIS
Pyelitis is a rare disease in children. In a great majority of the
cases the disease is due to an infection of the pelvis of the kidney with
the colon bacillus. I have seen but four cases of this nature,
all in girls under fifteen months of age. In two there was a coli-
cystitis ; in the others, the colon bacillus was found in pure culture.
Both of the latter were recovering from enterocoHtis.
The only symptoms in two of the cases were repeated severe
chills — a verv unusual occurrence in an illness in an infant — and a
high temperature w^ith a tendency toward wide fluctuations. The
severe chills, the temperature range, and the absence of other clinical
signs, together wdth a negative blood examination, suggested pyehtis.
Examination of the urine revealed the colon bacillus. In the two
other cases seen in consultation there was an irregular temperature,
ranging from ioo° to 105° F. , which had continued for several days and
which could not be accounted for. The urine was examined bacteri-
ologically with a view of clearing the diagnosis, which resulted in the
discovery of the colon bacillus. The patients were given two grains
of the citrate of potash every two hours— six doses being given daily.
In the cystitis cases two grains of urotropin were given three times
daily in addition to the citrate of potash. All made prompt recoveries.
THE MALE GENITALS
Practically every male child is born with an adherent prepuce
and with more or less constriction at the preputial outlet. The
penis is to be considered normal only when the foreskin can easily
be retracted, laying bare the glans.
The adhesions and constrictions may be relieved by moderately
stretching the foreskin and breaking up the adhesions with a fine
blunt probe, after which the glans should be cleansed, oiled, and the
foreskin drawn forward over it. The cleansing of the parts with
castile soap and warm water, which necessitates a retraction of the
PHIMOSIS. PARAPHIMOSIS 353
foreskin, should be practised at least every second day. This not only
keeps the parts clean, but prevents the later formation of adhesions
and a possible phimosis.
Hypospadias and epispadias are conditions essentially surgical,
and therefore are not considered here.
PHIMOSIS
Phimosis is a condition caused by a constriction or narrowing of
the preputial orifice, sometimes to a pin-point. In cases where the
foreskin is tightly bound to the glans by adhesions, the urine may be
emitted in drops; in other cases the prepuce "balloons out" during
urination and the urine dribbles away. The opening may be
sufficiently large to show under pressure the margin of the urethral
opening, and urination will be but little interfered with.
Treatment. — The cases in which urination is impeded require
prompt relief. This can be furnished temporarily by introducing a
small probe or a director and carefully slitting the skin with sharp-
pointed scissors until the glans is reached. The child should be
carefully held by an attendant during the operation and great care ex-
ercised in introducing the director. After the operation a wet dress-
ing of bichlorid of mercury, i : 6000, or a saturated solution of boric
acid should be applied to the wound until healed.
A few years ago I saw a case in which the probe had been intro-
duced into the urethra and followed up by the scissors, which had
made a slit involving one-third of the glans.
Phimosis may be productive of various nervous manifestations,
such as restlessness and irritability. In two of my cases convulsions
were apparently caused by phimosis. Both children had repeated
convulsions until they were circumcised. Both suffered from marked
phimosis with retained smegma and irritation of the prepuce.
Circumcision should never be delayed in cases of phimosis, as it
furnishes the only satisfactory means of relief. Stretching is very
apt to be followed by re-contraction, which only intensifies the origi-
nal condition, while the unavoidable laceration of the mucous mem-
brane may open a favorable field for infection. In hospitals and out-
patient work, examples are numerous of the harm resulting from
force and lack of cleanliness in the management of these simple and
easily remedied conditions.
PARAPHIMOSIS
Paraphimosis is produced by the retraction of a tight foreskin,
which later becomes so contracted behind the corona as to prevent
the return venous flow. As a result, the glans become greatly swol-
len, deeply congested, and edematous. Urination is impossible.
The cases which I have seen have all been produced by the mother
or nurse in an attempt to retract a tight foreskin according to
23
354 THE MALE GENITALS
the doctor's directions, after he had stretched the prepuce for
phimosis.
Treatment. — If the retracted skin is edematous, it may be punc-
tured in various places to let out the fluid. Reduction may then be
attempted by taking the glans between the thumb and the first and
second fingers of the right hand and making gradual pressure back-
ward against the thumb and first finger of the left hand, which grasps
the penis behind the prepuce. If the reduction cannot be effected in
this way, as occasionally happens, if the case is of long standing or the
contraction very tight, a longitudinal dorsal incision may be made in
the skin at the site of the constriction. After the reduction a wet
dressing of a saturated solution of boric acid or of bichlorid of mer-
cury, 1 : 10,000, should be kept constantly applied to the parts until
the swelling has subsided, when circumcision should be done.
BALANITIS
Balanitis is a swelling and inflammation of the foreskin due to a
local infection. Unskilled manipulation in stretching the prepuce
readily produces a laceration, opening up a means of entrance for bac-
teria. In severe cases the parts first show congestion and then edema.
I have seen patients with long foreskins which were twisted and
swollen to a size three or four times that of the penis. In advanced
cases there will be suppuration beneath the foreskin with a purulent
discharge from the orifice.
Treatment. — If the case is seen early, a wet dressing made by
wrapping the parts in gauze or old linen, which is saturated with an
ice-cold solution of bichlorid of mercury i : 10,000 and changed every
half hour, will usually be effective. If there is much edema, punc-
turing in several places, after disinfection, should precede the wet
dressing. If there is a purulent discharge, the sac should be gently
syringed at least twice daily with a 3 percent solution of hydrogen
peroxid, diluted one-half with water.
When the suppuration has ceased, with a return to normal of
the parts involved, circumcision should be done. Operation during
the acute stage, particularly with suppuration present, should be
avoided unless the condition is very urgent.
CIRCUMCISION
Many times during the year I am asked the question, "Shall we
have the baby circumcised?" My answer as to the advisability of
this operation, as a routine measure, is in the affirmative. The oper-
ation during the second week of life is a trivial matter. I am con-
vinced that it would be for the best interest of every male if he were
circumcised. In one out of every five male infants circumcision is a
necessitv both for his comfort and his health. In marked degrees of
phimosis and balanitis, circumcision is the only means of relief.
An important reason, to my mind, for the operation as a routine
ORCHITIS 355
measure, is that it settles at once and for all time the toilet of the parts.
The penis after a proper circumcision requires no further manipulation
on the part of the nurse. The daily retraction of the foreskin and bath-
ing of the parts is one of the best means of teaching the child self-
abuse. When this is not done every day or at least every second
day, trouble is sure to follow sooner or later, in the form of adhesions
and inflammation of the prepuce. The sensations produced by the
retraction and the washing are not unpleasant and the child soon
learns to produce them himself, through leg rubbing, hand pressure,
or otherwise. (See Masturbation, page 433.) Time and again, after
having stretched the foreskin and broken up the adhesions, operations
having been refused, I have had the case return in a few weeks with
the adhesions and the contractions as bad as before, the nurse or
mother, timid or neglectful, having failed to follow my directions.
With phimosis it may require considerable skill to draw the foreskin
forward after a retraction. It is not always safe to permit the
attendants to attempt it. Not a few times I have seen a paraphi-
mosis (page 353) which resulted from an inabiHty to bring forward a
retracted tight foreskin.
The dorsal sht, so often practised as a substitute for circumcision,
is to be used only as a temporary expedient, and as such maybe em-
ployed whenever circumcision is refused. Never, by any means, does
it take the place of circumcision. It inyariablv leaves a long, redun-
dant flap of skin, which easily becomes irritated, causing no little
discomfort. For the child, it also is a great temptation to mani-
pulation.
GONORRHEA IN THE MALE
Specific urethritis in male infants and "runabout" male children
is a condition seen but rarely, only one case having come under my
observation. This was in a four-year-old boy whose home was in a
small tenement and who had been repeatedly exposed through an-
other member of the family, who, having imbibed the fallacy popular
among the ignorant, hoped to rid herself of the trouble by giving it to
the boy!
The treatment in this case was with irrigation of the urethra with
a 1 : 10,000 solution of the permanganate of potash. The irrigation
was used at twelve-hour intervals for two weeks. After four weeks'
treatment the boy passed from under my care, having been placed in an
institution. During the last two weeks of the treatment the irrigations
were used once daily. There was no further trouble from the urethritis.
ORCHITIS
Swelling of the testicles is of very infrequent occurrence in the
young. I have seen but three cases — two complicating mumps, the
other occurring with an earlv gonorrhea.
The management is rest in bed, saline laxatives, if necessary, and
support of the inflamed testicles by a wide strip of adhesive plaster
356 THE MALE GENITALS
extending from thigh to thigh. The appHcation of warm sedative
lotions gives much rehef to the pain and discomfort and appears to
shorten the duration of the attack. Lead and opium solution, U. S.
P., applied on several layers of gauze and covered with cotton- wool,
was a satisfactory treatment in cases complicating mumps. The
dressing should be repeated every three hours. The gonorrheal case
also responded to this treatment, but required a much longer time
for resolution to take place. After an orchitis a suspensory ban-
dage should be worn for several months.
HYDROCELE
Hydrocele in the different forms in infants under one year of age
is frequently seen in children's institutions and in out-patient clinics
for children. Not a few of these cases have been under treatment
elsewhere. Drugs, such as the iodid of potash, have been given with
an idea of absorbing the fluid — a valueless procedure. Some of the
cases have been aspirated, and to others local counter-irritants have
been applied. If there is a very large and encysted hydrocele, and
if the parents are anxious for a speedy cure, aspiration with a hypo-
dermic syringe may be done, remembering, of course, that the opera-
tion must be aseptic in every detail.
In a recent case which came to the out-patient service of the
New York Polyclinic there h^-d been an aspiration performed. The
sac became septic and the child died from the infection.
Not more than one-eighth of the fluid need be withdrawn.
After the withdrawal of the needle, the site of the puncture
should be dressed with collodion and aristol, one-half dram of
aristol to one-half ounce of collodion. I have never found it nec-
essary to inject into the sac any form of irritant, such as carbolic
acid or iodin. In fact, fully 98 percent of the cases get well just as
quickly without treatment. If the hydrocele is a small one, our
management at the present time is to let it alone, and spontaneous
recovery follows in from two to three months.
UNDESCENDED TESTICLE
In the normal male at birth both testicles should be in the scro-
tum. In a considerable number of cases one or both testicles may
remain in the canal for a varying period, the descent usually taking
place during the first year. When such descent does not occur, the
condition may be considered abnormal. It is important not to mis-
take the condition for hernia and apply a truss. Not a little harm
may result from such an error.
A truss should never be used in such a case and operative pro-
cedures should be delayed until puberty, unless discomfort is ex-
perienced or disease can be proved. I have known many cases in
which descent did not take place until the third or fourth year. In
one case it was as late as the tenth vear.
THE FEMALE GENITALS
SIMPLE VULVOVAGINITIS
In simple vulvovaginitis there is an inflammation of the external
genitals with a secretion of rather viscid mucus. There is moderate
itching and a burning sensation about the parts — symptoms which
may resemble those of gonorrheal infection. The cases in which
there is a purulent discharge are particularly apt to be mistaken for
gonorrhea. Bacteriologic examination in such cases is the only
immediate means of differentiating the two diseases.
Ill-conditioned children and those improperly cared for furnish
the majority of the vulvovaginitis patients. The disorder is to be
regarded as one due to a low vitaUty rather than to a local infection.
Treatment. — Accordingly the management is largely constitu-
tional: Outdoor life, suitable food, iron and cod-liver oil, are to be ad-
vised, and, in short, all the measures advocated in the section on Deli-
cate Children are apphcable here. Bathing the genitals twice a day
with warm water and castile soap, followed by drying with absorbent
cotton, prepares the parts for a dusting-powder which I have found
useful in these cases. The powder used is of the following composition :
I^. Acidi borici gr. xxv
Pulveris amyli
Pulveris zinci oxidi aa oss
The dryer the inflamed surfaces are kept, the more prompt will be
the relief, so that if there is a tendency to a free secretion of mucus,
the powder may be applied at intervals of two hours.
A convenient means of applying the powder is w4th an insuffla-
tor, which may be obtained from any apothecary. After the parts
are packed with the powder, a dressing of old linen should be applied
and held in position by a napkin binder. The powder should be re-
appHed often enough to keep the parts dry.
GONORRHEAL VULVOVAGINITIS
The disease is seen with great frequency in out-patient work.
The specific infection is usually furnished by some member of the
family or by some other infected child. It is readily transmitted by
sponges, towels, napkins, etc.
In a typical case there is a profuse, greenish-yellow discharge.
The parts may be swollen and edematous. The course of the disease
is most protracted and there is no specific medication which we can
use locally or otherwise.
Treatment. — It seems to me, after treating in many different
ways several hundred of these cases, that keeping the parts clean
through douching does more toward terminating the disease than
does the use of any particular disinfectant wash or application.
357
358 THE FEMALE GENITALS
Douching of the parts is to be practised four times daily, if possible,
two quarts of water being used. It is useless to attempt the treat-
ment of a case which cannot be douched at least twice a day. It may
be remarked that it is a very trying treatment for both patient and
nurse. Such is certainly the case, but we are dealing with a disease
in which strenuous measures only give hope of cure. In order to use
the douche most effectively, the child is placed on its back on a
douche-pan. A glass, female catheter attached to a fountain syringe
is all the apparatus required. The catheter is passed about one-half
inch within the vaginal orifice and the water allowed to run. The
lower end of the bag should not hang higher than two feet above the
child's body. Boric acid is a safe drug in any household. For this
reason it is selected instead of bichlorid of mercury, permanganate
of potash or any other antiseptic. I am not at all sure that plain
boiled water would not answer just as well. It would be difficult,
however, to persuade many families to use the repeated douching
without the addition of some antiseptic to the water. Accordingly,
the mother or nurse is instructed how to prepare two quarts of a
saturated solution of boric acid. This is used as a cleansing agent.
After the parts are dried with sterile absorbent cotton, a dusting-
powder, the formula of which is as follows, is used very freely:
I^. Acidi borici gr. xxv
Pulveris amyli
Pulveris zinci oxidi aa oss
The powder is freely dusted into the vagina and over the diseased
surface after the douche, and at two-hour intervals, during the time
the child is awake, from early morning to late at night. I tell the
attendants to pack the parts with the powder. Over this is placed
absorbent cotton or gauze, which is covered with the napkin. The
attendants should be warned of the danger of infecting themselves
and other children in the household with towels, sponges, etc. ; in
fact, sponges should never be used in these cases. The danger of
infecting the eyes, not only of the patient but of the attendants and
others who may come in contact with the case, should be carefully
explained. When washing or drying is necessary absorbent cotton
or old linen should be used and immediately burned. A child suf-
fering from gonorrheal vaginitis should sleep alone. Cheese-cloth
napkins should be used and burned as soon as soiled.
A case treated as above may recover in three weeks, though usu-
ally from four to eight weeks are required, and in some cases the treat-
ment must be continued for months. After we have arrived at a
point where we consider the case cured, there will sometimes be a
renewal of the discharge and the treatment must be resumed.
Before the case is finally discharged at least two bacteriologic
examinations of the vaginal secretion should be made in order to
determine positively the absence of the gonococcus.
NERVOUS DISORDERS
HEADACHE
A complaint of headache on the part of a child should always re-
ceive attention. It is unusual in children, and when it is repeatedly
noted there is generally a good reason for it.
In children of any age headache may be an early symptom of
meningitis, particularly of the tuberculous form, in which the head-
ache may exist for days without other signs of illness. In eye-strain,
headache is a very prominent symptom, and may be the only evi-
dence that an ocular defect exists. In persistent headache that
cannot otherwise be satisfactorily explained I invariably have the
eyes examined. Headache is often the earliest sign of acute infec-
tious disease, it being usually a premonitory symptom of scarlet
fever, measles, or pneumonia. Persistent toxemia from any source
may be a cause of headache. It may occur in nephritis and in
malaria. The most usual toxic source, however, is the intestinal
tract, in which there is generally the association of anemia as well.
This condition may exist without constipation. Fatigue, as a result
of overwork at school, or hard play and unusual excitement may be
a cause of headache in neurotic children. It is frequently encoun-
tered in girls late in the school-year. Examination of the urine
may show marked indicanuria. In three cases recently seen by me,
headache was the only evidence of intestinal derangement.
Treatment.— The management of headache consists in the dis-
covery and removal of the cause. An ice-bag or an ice-cloth applied
to the head affords much relief in the acute febrile cases. Ocular
defects should have the benefit of rest and suitable glasses prescribed
by an oculist. Fatigue headaches are best controlled by limiting the
amount of work and providing long periods of rest. Headaches due
to intestinal toxemia with the usual accompaniment of anemia are
oftentimes most difficult to relieve. In spite of our best efforts the
intestinal digestion may remain faulty for a considerable time. A
change of residence and a radical change in the habits of life are
usually the best means of effecting a cure. The management of
these cases is considered in detail under Persistent Intestinal Indi-
gestion (page 162).
HYSTERIA
Hysteria in children is rarely seen before the third year. My
youngest case was three and one-half years of age when first seen by
359
360 NERVOUS DISORDERS
me, but the hysterical manifestations had been present for several
months. Mental, motor, or sensory manifestations may predominate
in an individual case, although all cases are associated more or less
directly with an absence of mental control. Girls are much more
frequently affected than boys, but some of the most typical cases
coming under my observation have been among the latter.
We are taught by neurologists that hysteria is almost invariably
of hereditary origin because of its apparent direct transmission from
parent to child. It must be remembered that the child, in addition
to being born of an hysterical mother, is thereafter in constant asso-
ciation with her. To my mind, in hysteria we have exemplified in the
most perfect degree the effect of environment. A neurotic hysterical
mother puts the whole family in a state of high nervous tension. I
know of several such instances. A neurotic irritable father will
make the whole family neurotic. I know of such instances also.
Fortunately for the offspring, both conditions are seldom combined
in one family. When they are, and I have the children of a few such
families under my care, the future of the children is discouraging.
When one of the parents is sufficiently normal to offset a reasonable
degree of neurosis on the part of the other, a stable equilibrium may
be maintained.
Imitation is one of the strongest characteristics of the growing
child. How often, when arranging with the mother a diet-list for
one of these nervous, ill-conditioned children, have I heard the
child say that he "hated" cereals, or "hated" vegetables, or
"hated" eggs or fowl; or that he "adored" some other article of
food, this adoration and hatred, particularly the latter, often influ-
encing the entire future of the child; for without a properly regu-
lated diet for every day in the year, only an inferior type of adult can
be the outcome. In such cases it will usually be found that the likes
and dislikes of the child are identical with those of the parents, whose
preference had often been expressed in the presence of the child.
"Hereditv" here furnishes to the parents a satisfactory explanation
of the child's limitations in diet. It will usually be found that
parents who live normally have children who eat normally.
Illnesses and ailments of different kinds should not be discussed
before nervous and impressionable children. Time and again an in-
vestigation of a peculiar pain in a child's head, side, or back which
cannot be accounted for by the physical examination will be ex-
plained bv a similar pain in some older member of the family.
Illustrative Cases. — In one family I have seen three generations
of genuine hysteria. In the first generation were the father and
mother. The father, chronically irritable and neurotic, was a busi-
ness man with large interests, rarely ceasing, when at home, to talk
about his ailments and their remedies. The mother had marked
hysteria. She indulged in frequent attacks, with apparent uncon-
HYSTERIA 361
sciousness lasting for hours. The daughter, brought up in this
atmosphere, through heredity and environment soon became
markedly hysterical. Both she and the mother, when some dispute
arose in the family, which was not an infrequent occurrence, would
have simultaneous attacks of hysteria. In due time the daughter
married and gave birth to a daughter who promises to maintain the
familv traditions with certain additions of her own.
I have under my care a girl seven years of age who is in deadly
fear of appendicitis and develops an attack of hysteria every time she
has a pain. She can locate "McBurney's point" and knows the
various stages in the development of the disease and the steps in the
operation for appendicitis. The mother's appendix, suitably pre-
served, is among the family relics, whence it cannot be removed.
The influence of heredity has perhaps had the effect of making the
child alert, precocious, and impressionable, and such favorable soil
and the constant association with the hysterical will almost surely
develop hysteria in a child.
Treatment. — General.— My results with hysterical children have
usually been very good or very poor, depending to a great extent
upon my ability to separate the child from its family, by this state-
ment the management of hysterical children is suggested. Re-
move the child, if possible, from the unfavorable family influence.
The boarding-school has effectually cured several of my cases. Here
the child is placed under the care of trained minds, teachers who
bring out the good and correct the bad by reason, precept, and
example, and who thus exert a continuous, beneficial influence. In
the boarding-school, plain diet, pleasant occupation, agreeable asso-
ciation, and a scientifically regulated life replace the spoiUng and
coddUng and oftentimes the unsuitable food, together with the end-
less nagging which the neurotic mother is very apt to indulge in,
with the best intentions, of course, but nevertheless with a most
unfortunate effect upon the child. If the child is too young for a
boarding-school or if admission is denied him, he should be placed
under the care of some kindly, well-balanced woman as companion
and instructor, and see as little of his family as possible, otherwise
but little can be expected from the treatment. Of course, the con-
ditions must be explained fully to the parents in order that they
may make an effort in the right direction as to their bearing toward
the child. If the former conditions as to intimate association with
the child continue, the good intentions, according to my observation,
may last only a very few days. It is impossible to reform the habits
of life of a neurotic adult. If he has grown that way, that way he
will remain. The only hope for the child is in his complete removal
from such unfavorable influences.
The further treatment of hysterical children consists in curtail-
ing the mental and physical activities, which almost invariably
362 NERVOUS DISORDERS
have been excessive. A rational scheme of Uving should be formu-
lated. "Showing off" the child to visitors and others should be
forbidden. If under ten years of age, he should retire at seven
o'clock every night and rise at seven every morning. It is under-
stood by the attendant that this does not mean 6.45 or 7.15.
Every day after the midday feeding, the child should rest quietly
in a darkened room for an hour or two. Whether he sleeps or not,
he rests in a recumbent position with clothing removed. For
such children exciting games of stress and competition of every
nature are forbidden. An outdoor life is encouraged. A bicycle, a
pony, an individual play-room in winter and a tent on the lawn in
summer should be provided when possible. School instruction may
be given, but the child is not to be crowded. The amount of study
and work depends, of course, upon the child's condition. Until the
tenth year, however, there should be but one morning session, of
from one and one-half to three hours. The child is given a tub-bath
or brine bath daily at 90° F. (page 31); at the completion of the
bath he stands w'ith his feet in warm water and is given a cool douche,
at 60° to 70° F., the spray tube being attached to a faucet; or cold
water may be poured down the spine. The application of cold water
should be for a few seconds only and should be followed by a brisk
rubbing with a rough towel, which should result in a decided skin
reaction.
Treatment During Hysterical Seizure. — During a hysterical seiz-
ure the child should be treated with kindness but with firmness. No
sympathy should be shown. The application of ice-water to the
face and chest is usually sufficient to break up an attack. In some
cases a certain amount of time appears to be required for a return to
the normal.
Drugs. — Sedative drugs, such as the bromids, should not be used.
Cases have come under my observation showing the bromid rash.
Such treatment, as also the use of the opium derivatives, cannot be
too strongly condemned. Drugs that increase the appetite and im-
prove nutrition should be given. I have found that iron and arsenic
answer well in these cases, as most of the patients show a secondary
anemia. For a child from five to ten years of age the following
prescription has been useful :
I^. Liquoris potassii arsenitis gtt. xc
Extract! ferri pomati gr. x
Quininae bisulphatis gr. Ix
M. div. et ft. capsulee No. xxx.
Sig. — Take one after each meal.
If constipation results from the use of the small doses of iron, one-
third to one-half grain of the extract of cascara may be added to each
capsule. If the child cannot swallow a capsule the following may be
used-
INFANTILE CONVULSIONS 363
I\. Liquoris potassii arsenilis gtt. Ixxij
Ferri et ammonise citratis gr. xxiv
Elixiris simplicis oss
Aquae q. s. ad 5iv
M.
Sig. — One teaspoonful after each meal in a glass of water.
The iron and arsenic may advantageously be alternated with pure
cod-liver oil — one to two drams after meals — each being given for
seven days. Alcohol should form no part of the medication of these
children. In using the so-called liquid proprietary foods, it is to be
remembered that some of them contain a considerable percentage of
alcohol.
INFANTILE CONVULSIONS
Convulsions in the newly born are usually of an entirely different
nature from those which occur after the third month. During the
early days of life, a convulsion is always a matter of serious import,
as it frequently is the result of a birth trauma and suggests a possibly
serious brain lesion, which may terminate in early death or result in
spastic paralysis or idiocy.
An appreciation of the causes of convulsions in older infants and in
young children suggests the treatment. The predisposing causes are
rachitis and other forms of malnutrition. While the rachitic child is
particularly susceptible, the most vigorous is by no means exempt if
the exciting cause is of a sufficient degree of severity. Uremic con-
vulsions (page 347) are always preceded by evident kidney involve-
ment, which may at once explain the cause of the seizure. The
cause in at least 90 percent of the cases is an irritation within the
gastro-enteric tract, due to a foreign body or undigested food, or
the absorption into the circulation of toxins — the products of decom.-
position in the intestinal contents. In two of my patients phimosis
with much smegma and irritation was the most plausible cause of the
convulsions. Both had had several convulsions, which were not re-
peated after circumcision was performed. In a small percentage
of the cases convulsions are the earliest manifestations of lobar pneu-
monia and scarlet fever. In fact, a convulsion may be a prodromal
symptom of any of the infectious diseases. One of my patients had
repeated convulsions until he was relieved of forty-three large round-
worms. So frequently is intestinal toxemia a cause that when a
child in apparent health is seized with a convulsion, it is safe to
assume that it is of gastro-enteric origin ; if such should not be the
case, the treatment directed toward relieving the digestive tract is
always advantageous, even if the convulsion is the first symptom of
lobar pneumonia or meningitis.
Treatment. — When a convulsion occurs, the patient should at
once be undressed and placed in a warm mustard bath (page 30)
at a temperature of 105° F. While in the bath, there should be
a brisk friction of the trunk and extremities, particularly the latter.
364 NERVOUS DISORDERS
At the same time an attendant may give an injection of soap-water.
In a great majority of the cases, in less than five minutes the child
will show evidence of a return to consciousness. As soon as he can
swallow, two teaspoonfuls of castor oil should be given. After a
seizure the patient should be kept very quiet for twenty-four or
forty-eight hours. An ice-bag or cold cloths should be applied to
the head and a guarded hot-water bottle kept at the feet. The diet
should be of the lightest. Chicken broth, weak beef-tea or chicken-
tea, and thin gruels should constitute the nourishment for a day or
two. A second seizure is more easily produced than the first, and a
third easier than the second, and as about 10 percent of the cases
of epilepsy are the outcome of infantile convulsions, it is the physi-
cian's duty to see to it that the indiscretion in diet which caused
the first attack is not repeated.
In case the attack is a very severe one, when the child is slow to
respond or when he passes rapidly from one convulsion to another,
chloroform inhalations, regardless of the age, should be given in sufh-
cient quantity to prevent the seizures until the intestinal canal can
be emptied and sufficient sodium bromid and chloral can be given by
mouth or rectum to prevent a recurrence. For a child under one
year of age, eight grains of sodium bromid and three grains of
chloral may be given by rectum in four ounces of mucilage of acacia.
After the first year, from three to five grains of chloral may be given
with from ten to twenty grains of sodium bromid. It is best to
attach to the syringe a soft-rubber catheter. No. 18 American, or
a small rectal tube. The catheter should be introduced for at least
nine inches, so that the solution may be carried to the descending
colon, where it will better be retained than if introduced with the
small hard-rubber tip simply within the anus. The bromid and
chloral may be repeated at intervals of from two to six hours, as
required to control the convulsions, and continued in diminished
doses as long as there are noticeable signs of nervous irritabihty,
such as twitching and involuntary muscular contractions. If the
child can swallow, five grains of sodium bromid, in one-half ounce of
water, may be given, and repeated at intervals of from one to four
hours, until the convulsions are controlled. Morphin hypoder-
maticallv is rarely required. It should be used only when other
measures fail. A child one year of age may be given g'g- grain, which
mav be repeated in two hours, though usually it will not be necessary.
Under one year ^q to -^^ grain may be given; under six months,
morphin would better be omitted.
Convulsions should never be lightly regarded. They may be seri-
ous in their immediate as well as in their remote possibilities. One
convulsion may produce cerebral hemorrhage which may change the
entire future of the patient, producing spastic paralysis or idiocy,
or both. About 10 percent of the cases of epilepsy originate in indi-
GYROSPASM — SPASMUS NUTANS 365
gcstion — the so-called "dentition convulsions." In these, rachitis
plays an important etiologic part. It is the duty of the physician, in
a given case, to ascertain the cause and so direct the future manage-
ment of the patient as to avoid a recurrence of the attack.
Under my observation several children under one year of age, in
apparently good health, have died of convulsions. In one we found
at autopsy one-eighth of an orange in the small intestine. In six,
the convulsions were due to enlarged thymus glands. In three of
these cases there were no previous symptoms of the existence of this
condition (page 449). They were strong robust infants. Two of
them were breast-fed. The diagnosis was confirmed by autopsy in
four, which included the breast-fed.
NIGHT-TERRORS
In night-terrors the child arouses from his sleep frightened, and
sometimes imagines that animals or persons are trying to injure him.
In a great majority of cases these phenomena are due to a deranged
digestion in a neurotic child. The attacks are very hable to follow
indulgence in unusual articles of diet, and when they occur repeatedly,
it will usually be found that the child is suffering from persistent
intestinal indigestion or that the evening meal is habitually beyond
his digestive capacity. Children subject to night-terrors should
dine at midday. The evening meal should consist of cereals, milk,
stale bread and butter, and a small portion of stewed fruit. The
patient should never be allowed to go to bed unless an evacuation
of the bowels has taken place during the previous twenty-four hours.
Overwork at school and anxiety regarding school duties and
lessons are often contributory factors to night-terrors. The cases
usually are readily relieved by proper treatment. If the case is
an aggravated one, the child should be removed from school, and all
exciting play and books of an exciting nature forbidden.
One of my patients, a boy who was four years of age when he
first came under my care, has had, during the past five years, two
attacks of night-terrors every year. One attack occurs on the night
of his birthday and the other on Christmas night. At these times, in
spite of my warnings and the repeated attacks, he is indulged by
his parents.
In the very nervous and irritable cases from five to ten grains
of bromid of soda may be given at bedtime. This should not be
continued longer than a week. If the child is delicate, anemic,
or suffering from adenoids, enlarged tonsils, or thread-worms, these
conditions, any one of which may contribute to night-terrors, should
receive proper treatment.
GYROSPASM— SPASMUS NUTANS
Gyrospasm is a functional nervous affection usually seen in chil-
dren under one year of age. I have seen one case in a child fourteen
366 NERVOUS DISORDERS
months of age. The disorder consists in a rotatory movement of
the head, sometimes from twenty to forty oscillations being made
in a minute. The movement may not only be lateral but vertical
also, which constitutes what is known as "head-nodding." In
one of my patients both the lateral and the vertical movements
took place. The oscillations are usually, but not invariably, asso-
ciated wuth nystagmus. I have seen a number of these cases in
out-patient clinics. Rachitis was present in all. Two of the children
were idiots.
The prognosis is good if the patient is mentally normal. It
is difficult to state the length of time required before the move-
ments will cease. It is doubtless a matter of several months. With
a disorder essentially chronic in character, the improvement is slow.
The mother becomes dissatisfied with the treatment and wanders
from clinic to clinic with her child. This probably explains in part
the large number of individual cases seen by pediatrists. I have
had the opportunity to give a few cases a fair trial with sodium
bromid — from twelve to eighteen grains daily — a treatment which
is generally advocated for this condition, but have failed to note
any special benefit from its use. With an increase in age and im-
provement in nutrition, the cases which I have followed at their
homes have gradually improved and recovered.
TETANY
Tetany occurs oftentimes in association with or following ex-
haustive diseases. It may occur, however, without any such rela-
tion to other affections. In my cases there have invariably been
rachitis, malnutrition, and intestinal indigestion of a pronounced
type. The muscular spasms may involve any portion of the body,
but the extremities are most frequently affected.
Treatment. — Inasmuch as intestinal toxemia and malnutrition
are the apparent causes of the phenomena, attention directed to the
intestinal canal and nutrition is indicated. The child should be
given two drams of castor oil, and milk should be excluded from
the diet for a day or two until the stools become normal. This
treatment alone has cleared up some of my cases. When the spasm
persists, bromid of soda should be given in two-grain doses every
two hours, giving at least six doses in twenty-four hours, for a child
one year of age or younger. The patient should be kept very quiet
during an attack, as undue excitement may precipitate an attack
of laryngismus stridulus or convulsions which may be of a very
serious nature. A hot bath at iio° F. for a few moments, and
repeated at six-hour intervals, will often have the desired relax-
ing effect.
The later treatment consists in regulating the child's nutri-
tion. If the malnutrition is extreme or if the infant is under six
CHOREA — ST. VITUS' DANCE 367
months of age a wet-nurse is the safest means of nutrition. A
wet-nurse, however, is not practicable in children beyond one year
of age. There is considerable uncertainty as to how these older
children, those approaching the twelfth month, will take the
breast. When the wet-nurse is impossible or impracticable, an
adjustment of the food to the child's digestive capacity is demanded
along the Unes laid down in the section on Malnutrition.
Not a few of the infants who develop tetany have been on a
low proteid such as is furnished by the proprietary foods and con-
densed milk, or they may have had a low proteid capacity, which,
as far as the nutrition is concerned, is practically the same thing.
The proteid elements in the diet, therefore, should be kept well in
mind in feeding these cases. It is in such cases that peptonized
milk (page 115) is indicated. The milk should always be given
raw unless the station in life or season of the year forbids it.
When it is possible, children who have had tetany should
in every instance be given the advantages furnished by climate.
An outdoor life in the country with open windows at night
are necessary for rapid relief of the weakened physical condi-
tion which underlies the disorder. The patient should be given
a brine bath (page 31) at bedtime. It is followed by inunc-
tion with an animal fat during the cooler months, goose oil being
preferred. As these patients are usually suffering from a secondary
anemia, one-half grain of the citrate of iron and ammonium may be
given twice or three times daily after feeding. The hygienic and
dietetic management of these cases is practically the same as that
suggested for marasmus and malnutrition.
CHOREA— ST. VITUS' DANCE
The management of chorea depends entirely upon the degree
of severity of the attack. It may be necessary in extreme cases
to keep the child in bed from three to four weeks. In other cases,
where the attack is milder in character, the enforced rest may do
harm. Formerly I treated more cases on the extreme rest plan
than I do at present. For cases in which the involuntary move-
ments are so marked as to interfere with locomotion and prevent
the child's feeding himself, rest in bed for a week or two is strongly
advised. In my observation, it is mental repose which the patients
particularly require, and if this can best be obtained in bed,
then the bed is the best place for the patient. If an absence of
mental excitement and stimulation can be secured with a reason-
able amount of outdoor life and exercise, so much the better for
the patient. An important feature to be remembered in the manage-
ment of choreic children is that they must not be allowed to become
fatigued either physically or mentally.
In the cases which have been confined to the bed for several
368 NERVOUS DISORDERS
days or weeks, a gradual return to the usual habits is best. The
child should be taken up for one-half hour the first day, increasing
the time out of bed one-half hour daily, until he returns to his usual
habits of life. School for the choreic patient is out of the question,
no matter how mild the case. In the great majority of cases, play
with other children will have to be interdicted. Books and play
of an exciting nature are particularly to be avoided. Specific
instructions as to the amount of physical and mental rest required
cannot be given so as to apply generally in the management of
chorea. The physician should particularly remember that there
must be no bodily fatigue and no mental stimulation of any nature
whatever. How best to bring this about will depend upon the
child and his environment.
In two instances I have been obliged to remove the child from
his home and place it among relatives. The influence of the mother
was such as hopelessly to prevent the child's recovery. Cases
not sufficiently severe for confinement in bed, should be made to
rest for two hours every day after dinner.
Striimpell in his text-book states that the association of chorea
and rheumatism is so close that it is impossible to separate them.
Hirt, in discussing ner\'ous diseases, expresses the view that there
is a common toxic etiologic factor which, affecting the cortex, pro-
duces chorea ; but affecting the joints, gives rise to acute articular
rheumatism. That the association of chorea and rheumatism is
a most intimate one, has been borne out by the observations of
many cUnicians. A trifle over 50 percent of my cases of chorea
either gave a history of having shown rheumatic manifestations,
or thev showed evidence of it when first seen. In 80 percent of my
cases there was some association with rheumatism, either in rheumatic
parents or in the actual manifestations of rheumatism at some time
in the patient's life. So impressed have I been by the above facts,
and by the similarity of the clinical signs of these supposedly distinct
diseases, that I believe them due to the same toxic agent. This
is further proved by the results of treatment.
Anti-rheumitic Treatment. — By treating every case of chorea
as though it were rheumatism, my results have been strikingly
better. Not only is the child given the salicylates, but he is
put on an anti-rheumatic diet — given meat but once even,^ sec-
ond dav, and but little sugar. The salicylate of soda may be given
in smaller doses than are used in acute articular rheumatism — about
five grains three times daily, with an equal amount of the bicar-
bonate of soda, being suitable for a child from six to ten years of
age, the soda being given between meals. To children of this age
the salicylate may be given either in capsule or in solution. In
young children, the drugs in solution are more easily administered.
During the past year I have given aspirin to a few patients in whom
CHOREA — ST. VITUS' DANCE 369
the digestive functions were weak or who could not take the saU-
cylate of soda. In using the saHcylate of soda, Merck's or Squibb's
preparation should always be indicated. In using salicylate of
soda or aspirin for a considerable time, it is well to remember that
they may interfere with the appetite and digestion, no matter how
great the care exercised in their use. For this reason it is my custom
to give them intermittently — five days of medication being fol-
lowed by five days of rest.
I have found that by putting the patient on the anti-rheumatic
treatment much less arsenic is required, and that the patient usually
makes a more prompt recovery. I have never been olaliged to resort
to the large dosage of twenty-five to thirty drops of Fowler's solution
three times a day, as suggested by Seguin. It is exceedingly rare
that it is necessary to give more than ten drops three times daily
in order to procure satisfactory results. In spite of the value of
the anti-rheumatic treatment this alone will not answer, as I have
proved to my satisfaction in not a few cases. The administration
of the arsenic and the salicylate and the dietetic regime are begun
at the same time. The salicylate of soda is given at once at the
commencement of the treatment in as full doses as we expect to
give it. Arsenic is commenced in small doses, which are grad-
ually increased in order to establish a tolerance of the drug. Fowler's
solution of arsenic is usually employed. In order that no error
be made in its administration, a table similar to the following is
given to the mother or attendant. For a child six years of age
on the first day after each meal, two drops should be given as indi-
cated below. Thereafter, the dosage is increased by one drop every
twenty-four hours, according to the following schedule :
DOSAGE OF fowler's SOLUTION FOR A CHILD SIX YEARS OLD
1st day — Morning, 2 Drops. Noon, 2 Drops. Nis;ht, 2 Drops
2d "■ " 2 " "2 " ^" 3 "
3d " " 2 " "3 " " 3 "
4th " " 3 " "3 " " 3
This rate of daily increase is continued up to the third week,
after which time the dosage should range from five to ten drops
three times a day. For a child of from eight to ten years of
age the amount may be increased to from twelve to fifteen drops
three times a day. I have never found it necessary to give more
than twelve drop doses to girls of from thirteen to sixteen years
old. A very recent aggravated case in a girl fifteen years of age
made a complete recovery in three weeks under the above scheme
of diet, the use of aspirin, ten grains daily after meals, and Fowler's
solution up to twelve drops after each meal. With the improvement
of the case, the diet should be continued. The medication may grad-
ally be reduced after all the symptoms have disappeared. It should
24
370 NERVOUS DISORDERS
be continued, however, in from one-third to one-half the quantity,
for three weeks after the disappearance of all nervous symptoms.
Supplementary Treatment. — It should be remembered that
children who have once had chorea are very susceptible to recur-
rent attacks. This is also the case with children who have had
rheumatism. After one attack of chorea the danger of a return is
explained to the mother, who is asked to bring the child for exami-
nation at the first suggestion of involuntary muscular twitching.
In addition to this, children who have had chorea, as well as those
who have had rheumatism, are allowed meat but once every second
day, and in no case is an excessive use of sugar permitted. Candy
is usually forbidden. Believing that these cases are rheumatic in
origin, when the attack is over I order the child to receive ten grains
of bicarbonate of soda daily for five days out of every fifteen. In
this way, with a reasonably quiet home life and no school contests
for prizes, etc., a recurrence will in all probability be prevented. In
giving arsenic, mothers are advised that in the event of abdominal
pain, diarrhea, coated tongue, foul breath, vomiting, or puffiness
under the eyes, the drug is to be discontinued for at least two
days. Upon resuming it, the minimum dose is again given with
the same gradual increase.
Children vary greatly as to their tolerance of arsenic. A boy
seven years old, under my care at the present time, cannot take
more than four drops of Fowler's solution three times a day.
HABIT SPASM
By habit spasm we understand a semi-incoordinate movement
of some portion of the body. The term "semi-incoordinate" is
used advisedly, because the spasm may be controlled when the
child's attention is directed to it, this being one of its distinguish-
ing features. The muscles involved in the spasm are usually those
of the head, face, or arm. The nose may be drawn up, the chin
down, or the head to either side. The muscular spasm is worse
when the patient is tired and occurs more frequently under excite-
ment. While these children cannot be said to have chorea, there
is a close association of the two conditions, there being but a step
from habit spasm to true chorea. Habit spasm is most frequently
seen in those of rheumatic inheritance — those who have had previ-
ous attacks of chorea or rheumatism or the respiratory manifes-
tations so frequentlv seen in children of the rheumatic type.
Treatment. — The management is dietetic, hygienic, and medi-
cinal. I allow these patients a small portion of red meat once a
dav. Sugar is given in sufficient amount to make the food pala-
table. The vegetable and legume element in the diet is made
prominent. The patient will usually be found poorly nourished,
often he is suffering from a secondary anemia, so that a diet best
EPILEPSY
371
calculated to improve his general condition should be prescribed.
He should be given a salt bath (page 31) at bedtime, followed by
an oil rub one ounce of goose oil, unsalted lard, or olive oil being
rubbed into the skin immediately after the bath.
Temporary absence from school or a lightening of school duties
and an outdoor Hfe are of much aid in the successful management
of a case. The child should not be allowed to do anything of a
strenuous nature. Hard play and any amusements of an exciting
character are to be forbidden. Fatigue must be avoided. Rest
after the noon-day meal for an hour or two is strongly recommended.
As to medication, the scheme suggested for chorea is also appli-
cable here. If there is anemia, iron is given, preferably in the form of
the extractum ferri pomatum, 1 grain three times a day. In those
children who cannot take cream or butter, cod-liver oil in teaspoonful
doses is a valuable addition to the treatment. The iron may be
alternated with the cod-liver oil, each being given for five days.
If there is a rheumatic history or inheritance, aspirin or salicylate
of soda, preferably aspirin, is given in capsule with the iron. The
following is a favorite prescription for a child five vears of age :
I^. Liquoris potassii arsenitis gtt. iij
Extract! ferri pomatum o^r ss
Aspirin ' . ' .' ' '|r! iij
Sig. — One dose; to be given in capsule after each meal.
The use of arsenic, while of advantage, does not appear to be as
valuable here as in chorea.
Habit spasm being practically under the control of the will,
should be strictly forbidden, rewards being given and punishments
imposed, as seem to answer, best.
EPILEPSY
While the underlying conditions as regards the pathology and
etiology of epilepsy are better understood as a result of the 'study
which has been devoted to the subject during the past few years,
our knowledge as to the successful treatment of the disease has not
increased materially, if we are to judge from the recent writings
of the best authors. While appreciating the value of workers hi
this field, I am sure that there is a disposition on the part of some
writers to draw too narrow lines of differentiation between different
types of the disease.
Treatment. — In the management of epilepsv we can promise little
or nothing as to cure, and practicallv all we can hope to do is to
diminish the frequency of the attacks which characterize the dis-
ease, whether it be a grand mal or a petit mal. Proper nutrition,
rational habits of living, and pleasant outdoor occupations are of
inestimable service in the management of the epileptic. The
method of management which has served me best has been, first.
372 NERVOUS DISORDERS
along general and hygienic lines ; and, second, by the use of drugs.
It should be our object to make thv=^ patient physically as normal,
as vigorous, and as resistant to attacks as lies in our power.
Visual defects, enlarged tonsils, adenoids, phimosis, and irritant
skin lesions must all be corrected before beneficial results are to
be expected from any line of treatment. The patient is then
placed under the best possible environment permitted by his station
in life. Outdoor life, sports, and games are encouraged, always
keeping within the lines of moderation. The child should sleep
in a cool room with the freest possible ventilation at all seasons of
the year. If he is a school-child, he is instructed at home and the
sessions are made short and the studies easy. The patient in his
work or play is never allowed to reach the point of mental or
physical fatigue. This, to my mind, is most important. Emotional
plays at the theater and exciting amusements elsewhere are forbid-
den.
The diet is to be adjusted to the child's digestive capacity. A
diet suitable for his age is given, just as for normal children (page
128), meat being allowed only once a day. As intestinal indigestion
and toxemias from intestinal sources are unquestionably important
etiologic factors in not a few cases in causing a recurrence of the
seizures, careful attention to the bowel function and diet are most
important features of the treatment. The epileptic patient under
my care is never allowed to pass over twenty-four hours without an
evacuation of the bowels, and if, in the opinion of those in charge,
it is not as copious as usual, an enema is given. If there is a sug-
gestion of constipation, the treatment with the oil enemata, as re-
commended for chronic constipation (page 167), is instituted. In
cases in which heredity and toxic influences prevail, the im-
portance of attention to the diet and habits of life cannot be
overestimated. When there is a focal lesion, attention to the details
of living will have less influence, but always surely some influence,
in diminishing the frequency and severity of the seizures by es-
tablishing a more vigorous physical resistance.
Among those who are unable to give the patient suitable atten-
tion at home I urge that he be placed in one of the excellent insti-
tutions devoted to the care of epileptics.
There are few drugs in the pharmacopeia, particularly those
of a sedative nature, that have not been used at one time or
another in the treatment of epilepsy. The bromids unquestionably
serve our purpose in controlling the seizures better than does any
other form of medication. The size of the dose is variable. Because
of their peculiarly depressing effects upon the child's mental con-
dition, the bromids should be given in as small quantities as are
compatible with the beneficial results desired — a diminution of the
number of the convulsions. Ordinarily ten grains of sodium bromid
MENINGITIS 373
may be given, well diluted, in one-half glass of water after meals,
to a child ten years old, the amount to be increased or diminished as
the progress of the case demands. If the convulsions are nocturnal,
large doses — from twenty to thirty grains — should be given at bed-
time to a child of ten years. In the event of the drug being discon-
tinued to the point where it is given but once a day, the time
selected should be bedtime. With continued improvement under
the bromid, it may be given on alternate nights, and then every
fourth night.
Illustrative Case. — I have now under my care a case which
I have treated for several years and which promises well. The
first convulsion occurred at the fifteenth year. It was a typical
nocturnal seizure. Fifteen grains of bromid with five drops of the
tincture of belladonna were given three times daily for three months,
when the amount was reduced to thirty grains daily. This was
continued for one month, when a death occurred in the family
which doubtless helped to incite a second attack. At this time,
the patellar reflex being scarcely perceptible and the bromid rash
considerable, the drug was discontinued. At the end of two months
the daily dosage was placed at twenty grains, with ten drops of
the tincture of belladonna. This was continued for four weeks,
when there was a third attack, without any apparent cause of an
exciting nature, but the patient had allowed herself to become obsti-
nately constipated. This was her last attack. Three years have
since intervened. The bromid has been gradually reduced, first
to ten grains daily at bedtime, then every other day, and now it
is taken every fourth day only.
MENINGITIS
Holt's classification of meningitis as epidemic cerebrospinal,
acute simple (due to the pneumococcus or other pyogenic organisms) ,
and tuberculous, covers the matter of division of types better than
any other.
The management of the different forms of meningitis is, in the
main, the same, and I know of no disease in children in which so
little hope is to be held out for the patient. A certain proportion
of the cases of cerebrospinal meningitis recover, but the recovery
or fatal issue is governed by the character of the infection, to an
extent greater than perhaps we are willing to admit. The immediate
mortality in the different epidemics of cerebrospinal meningitis
varies from 60 to 90 percent. Not a few of those who survive were
better dead. As to the number of such cases which recover with
normal mentality, normal coordination, vision, and hearing, statis-
tics are very unsatisfactory. I have had not a few of the so-called
cured cases admitted to my hospital wards who will be hopeless
invalids for the remainder of their lives. I have seen cases of cerebro-
374 NERVOUS DISORDERS
spinal meningitis so mild that a diagnosis could not have been posi-
tive without a lumbar puncture, and which recovered without
treatment, and I have seen cases so severe that the patient died in
twenty-four hours in spite of every known means of relief.
The most severe cases, however, should not be despaired of in
spite of the decidedly hopeless outlook. I saw a case at different
times in consultation during the recent epidemic in New York city —
a boy six years of age who was confined to his bed for fourteen
weeks, unconscious for four weeks, blind for four weeks, and deaf
for five weeks, who was unable to swallow and was nourished
by rectal enemata for two weeks, and yet, according to the state-
ment of his family physician, he made an excellent recovery and
is normal in every respect. Physicians who pursue a special line
of treatment, and who have the good fortune to meet with mild
cases, sometimes become optimistic, and feel that their special
scheme of management is the one to be depended upon; further
observations, however, prove the futility of their methods.
Treatment. — The most we can do in cerebrospinal meningitis is
to nourish the patient and lessen his discomfort, and in this way aid
him to resist the infection. By the use of repeated lumbar punc-
ture, we can, in the majority of the cases, appreciably relieve the
patient. The pulse and the respiration improve and the urgency of
the nervous phenomena, the opisthotonos, and the excessive hy-
peresthesia may be temporarily relieved. There are no rational
grounds for expecting lumbar puncture to be curative, neither may
the injection of disinfectant drugs into the canal be expected to
aid in controlling the disease.
Lumbar Puncture. — Lumbar puncture (page 376) may be prac-
tised as frequently as once in twenty-four hours, the frequency
of its use depending, of course, upon the condition of the patient
and the relief afforded. Its more frequent use than once in
twenty-four hours, as has been suggested, is not, however, to be
advised. The amount of fluid withdrawn depends upon the pres-
sure in the canal as indicated by the passage of fluid through the
canula, from one to three ounces being the usual amount withdrawn.
The usual surgical precautions as regards asepsis should be observed
in performing the operation. One dram of aristol in one ounce of
collodion, applied with a camel's-hair brush, makes a suitable pro-
tective dressing after the withdrawal of the canula.
Warm Packs. — The warm pack or warm bath at 105° F., by les-
sening the cerebral blood-pressure, may also assist in relieving the
more active nervous manifestations. If the bath is used the child
should not be kept in it longer than three minutes. I usually prefer
the hot pack. A large bath towel or medium-weight flannel sheet is
wrung out of water at 110° F. and wrapped around the child's body
from the waist down. This is repeated at one-half -hour intervals for
MENINGITIS 375
three hours, when, after a period of rest for an hour or two, the packs
may be resumed.
Q{(,1 — Xhe proper nutrition of the patient with meningitis is
oftentimes a matter of no Uttle difficuhy . The child may either refuse
the food or he may be unable to swallow. Nutrition by means of
the rectum or colon may be of assistance for a few days, but it
cannot be relied upon for long periods. The parts become intolerant
and the nutrient enemata are expelled. Feeding by means of
gavage is alwavs to be employed when other means fail. The
younger the child, the greater will be our success with it. The
feeding should not be attempted oftener than at four-hour intervals;
usually every six hours suffices. Completely peptonized full milk
(page 115) is usually given in quantities suitable for the age. After
a few trials of gavage, the patient may take the nourishment by
the usual method or the gavage may be kept up indefinitely.
Sedatives. — Sedatives may be employed with a view to saving the
strength of the patient. Morphin, codein, the bromid of soda, or chlo-
ral may be given. As morphin and codein increase the usual exist-
ing constipation, their use should be very temporary. The bromid of
soda for those cases which may require the protracted administra-
tion of a sedative, answers better than any other form of medi-
cation. For an infant under eighteen months of age, from two to
four grains may be given at intervals of from two to three hours,
according to the results. In case the nervous symptoms are very
urgent, one-half to one grain of chloral may be added. Should
administration by mouth be impracticable, the sedative may be
given by rectum, and should be introduced by means of a rectal
tube inserted at least nine inches. In using the bromid and
chloral in this way, twice the amount of chloral and thrice the
amount of bromid should be given that is employed in stomach
administration. After the eighteenth month, from one to two
grains of chloral and from four to eight grains of the bromid may be
given by stomach. It should be well diluted and repeated as often
as may be necessary. In case it is to be given by rectum, it should
be diluted with at least four ounces of water, and proportionately
more given, as suggested for younger children. The colonic admin-
istration of salicylate of soda in cerebrospinal meningitis is advised
by Seibert. I have not used it in a suihcient number of cases to
warrant an expression of opinion as to its value.
In acute pyogenic meningitis and in the tuberculous form, the
management is in accordance with the means suggested above, with
an exception of the hot baths or packs, which are rarely called for.
The lumbar puncture is to be used for diagnostic purposes and with
a view to relieving the urgency of the nervous symptoms.
The proved cases of these two types seen by me have invariably
been fatal. Pyogenic cases live perhaps from two to three weeks.
376
NERVOUS DISORDERS
Tuberculous cases rarely pass the sixth week after the appear-
ance of diagnostic signs.
LUMBAR PUNCTURE
The site selected for lumbar puncture is a point parallel with
the crests of the ilia and between the spinous processes of the third
and fourth lumbar vertebrae. The child should rest on its side
(see Fig. 40), sufficient pressure being exerted on the buttocks
to make the spinous processes prominent. The Quincke needle
(Fig. 41) should always be used in making the puncture. The
stylet which fits the beveled edge of the point of the needle effect-
L^
Fig. 40. — Position for and Site of Lumbar Puncture.
ually prevents its being plugged. The skin for several inches about
the site of the puncture should be scrubbed with the tincture of
green soap and alcohol. The physician's hands should be thoroughly
disinfected. Considerable force may be necessary in order to enter
Fig. 41.— Quincke's Needle
the canal. When there is a sudden giving way of the obstruction
to the progress of the needle, we know that the canal has been
entered. The puncture may be made in a line with the spinous
processes or from the side, the needle being passed between the
laminae. When the point of the needle has been introduced into
the spinal canal, the stylet is withdrawn. The cerebrospinal fluid
CHRONIC INTERNAL HYDROCEPHALUS 377
may escape with force in a stream as a result of the pressure or it
may exude drop by drop. A sterile tube should be in readiness
in order to collect the fluid for examination.
Lumbar puncture is often of value for diagnostic purposes, but
its therapeutic value is practically nil. In meningitis the with-
drawal of an ounce or two of the fluid will sometimes furnish tem-
porary reUef to the patient. The retraction of the head and the
spasticity will generally be relieved for a time. I have repeatedly
withdrawn the fluid in such cases, where there was a tense bulging of
the fontanel, and after two or three hours have passed, the fontanel
would still be found depressed; it would soon become prominent,
however, and in eight or ten hours it often would be as tense as be-
fore. The advantage of lumbar puncture, therefore, is largely of a
diagnostic nature, only temporary reUef being furnished the patient
by the operation. The introduction of drugs into the canal for
bactericidal purposes is valueless.
CHRONIC INTERNAL HYDROCEPHALUS
When hydrocephalus in infants is mentioned without definite
qualifications, the internal is always the type referred to, the external
being of extreme rarity. The discussion of this aff"ection will neces-
sarily be brief, for after the treatment of a considerable number
of such cases in hospitals and institutions I am unable to recommend
any treatment that has proved of the slightest value.
A new operative measure is now being employed by Dr. A. S.
Taylor, of New York, which consists in tapping one of the lateral
ventricles and establishing drainage by means of strands of chro-
micized catgut conducting the fluid to the subarachnoid space,
where its absorption is hoped for. The operation is described by
Dr. Taylor as follows:
"An osteoplastic flap about two inches in diameter is turned
down, with its hinge over the base of the mastoid and just above
the level of the horizontal lateral sinus. In the lower part of the
dura mater thus exposed, a semicircular flap, base downward and
about one inch in diameter, is made. Frequentlv there are one
or two distended veins beneath this dural flap, and they should not
be damaged, for their walls are so friable that neither clamp nor
ligature is of much use, and the bleeding is annoying. The brain
immediately protrudes through this dural window. A slender
aspirating needle is passed through the second temporo-sphenoidal
convolution (which is the one protruding), inward and slightly
upward until it enters the ventricle, when the clear fluid spurts
out and is collected in a sterile tube for bacteriologic examination.
Only a A^ery small amount should be allowed to escape in this way.
"The thickness of the brain tissue is measured by observing the
length of needle inserted when the fluid begins to escape.
378 NERVOUS DISORDERS
"The drain is now made of No. 2, forty-day, chromic catgut.
Three loops (six strands), about an inch and three-quarters longer
than the thickness of the brain, are bound together by a loose spiral
of catgut, starting at one end and stopping so as to leave an inch
and a quarter of the loops free. In other words, the drain consists
of a shaft of six strands of catgut a half -inch longer than the brain
thickness, and spreading from its base, three free loops of gut an
inch and a quarter long. Around the shaft of the drain, but not
covering its tip, are rolled three layers of cargile membrane. With
a long, narrow-bladed thumb forceps the tip of the drain is seized
and carried into the ventricle along the tract made by the aspirat-
ing needle. The tip projects about one-half inch into the ventricle.
The free loops of gut are slipped under the dura, between it and the
brain surface, in different directions, but chiefly downward toward
the great lymph spaces at the base of the brain. A sheet of cargile
membrane is sUpped between the dura and the catgut loops to pre-
vent adhesions. Usually by this time sufficient ventricular fluid
has escaped, so that the brain no longer protrudes through the dural
window. The dura is sutured with catgut, the bone-flap is held
in place by three or four chromic catgut sutures, the deeper soft
tissues by catgut, and finally the skin with silk. A good-sized
sterile dressing is applied with some pressure,
" The site just above and behind the ear, with the puncture
through the second temporo-sphenoidal convolution, was chosen
because the body of the lateral ventricle is drained. Where anom-
alies of the ventricles exist they most frequently involve one or the
other of the horns. Afterward, moreover, the escaping fluid leaves
the brain in close proximity to the great lymph spaces and venous
sinuses at its base — a fact which favors its rapid absorption. The
right side of the brain is chosen because, if any irritation of the
motor areas occurs, the left side of the body is involved, and more
particularly Broca's speech center is not disturbed, as it lies in the
left hemisphere. The approach to the brain is easy; the brain
need not be handled, and is but slightly injured in the insertion
of the drain."
ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS
In poliomyelitis we meet a disease by which we are singularly handi-
capped. Prophylaxis amounts to nothing. The strong and the well
are as frequently attacked as the delicate — perhaps more frequently.
Treatment. — During the acute stage of the involvement of the
cord our efforts count for httle. We order that the child be kept quiet
in bed, that a laxative be given, and that he receive light, easily
digested nourishment, and then, as far as the immediate conditions
are concerned, we have done our little, but our all. I have used
the bromids and ergot and the iodids internally, and ice-bags and
DIPHTHERITIC PARALYSIS 379
blisters over the spine at the site of the lesion, and am yet to be
convinced that they are worthy the annoyance which they cause
the patient or that the drugs are worth the indigestion they are
apt to occasion. That the disease is due to an infection is probable,
and in a given case our hope must be that the infection will be
mild in character. The degree of involvement determines the re-
sulting atrophy and loss of function.
Later Treatment. — From ten days to two weeks after the acute
stage has passed our efforts should be directed toward maintaining
the nutrition of the affected muscle or groups of muscles. This is to
be done by mechanical means, electricity, and gymnastic exercises
(page 539).
The beneficial action of electricity consists largely in exercising
the muscles no longer under voluntary control, and thus increasing
their circulation and nutrition. The immediate object of the elec-
tricity is to induce contraction of the muscles. Either the faradic
or the galvanic current may be used. The faradic should first be
tried, and if to this there is no response, the galvanic should be
used. Sittings of from five to fifteen minutes may be desirable,
depending somewhat upon the age of the child and the age and ex-
tent of the lesion. The longer the duration of the disease, the
longer should be the sittings. Once daily the parts should be
massaged by one skilled in the work. When this is not available
the mother or nurse may undertake with some advantage the sys-
tematic manipulation of the affected muscles by kneading and
rubbing. The further management is orthopedic, and consists in
the prevention of deformities by the use of splints and braces and
their correction by tenotomies and tendon transplantation.
DIPHTHERITIC PARALYSIS
Every child with diphtheria should be watched and treated
as if diphtheritic paralysis were expected. It has occurred, to some
extent, in 9 percent of my cases. The first sign of irregularity
of the pulse calls for an enforced recumbent position and the use
of strychnin. If marked irregularity of the heart action occurs
early in an attack of diphtheria, myocarditis may be suspected,
a condition which calls for as active measures of treatment as does
the irregularity which may occur later, from the tenth day to the
third week of convalescence, which usually means nerve involve-
ment. The two conditions may occur in the same individual.
The soft palate and the muscles of deglutition are most frequently
involved. There may be paralysis of the pharynx and larynx.
Next in frequency the muscles of the extremities are affected. It
has been my experience that if the heart is to be attacked, signs
indicating it will be noticed early — soon after the paralysis of other
parts is apparent — or it may be the earliest symptom, the first
380 NERVOUS DISORDERS
warning being the heart's irregularity, which maybe the only evidence
of its involvement.
Treatment. — If after ten days from the onset of throat para-
lysis, or paralysis elsewhere, there is no evidence of cardiac
involvement, it will be unusual for it to develop later, although
this is by no means certain. Should it occur, absolute rest in the
recumbent position is important. The patient should be con-
stantly under the eye of an attendant. He must not be allowed
to turn over in bed or to raise his head without assistance. A
hypodermic syringe loaded with j^q grain of strychnin and o^^o grain
digitalin should be in constant readiness. Strychnin should be
given these patients throughout the entire illness and well on into
convalescence. In these cases we rarely have to deal with children
under eighteen months of age, my youngest case of diphtheritic
paralysis being fifteen months old, so that in the consideration of
doses only children over one year of age will be referred to. For
a child from one to two years old, 3^77 grain of strychnin may be
given at three-hour intervals; from two to four years of age, from
lio" to Y^Q grain at three-hour intervals. After the fourth year,
xio to Y^o^ grain may be given at three-hour intervals. When there
is marked rapidity of the heart's action with irregularity and rest-
lessness in those under three years of age, from one to two drops
of tincture of strophanthus may be given with yV to yV grain of
codein, and repeated at two-hour intervals. After this age one and
one-half to three drops may be given with to to |^ grain of codein
at two-hour intervals. The codein is to be discontinued as soon as
the restlessness ceases. For those in whom there is simply paralysis
of the muscles of deglutition or of the extremities, small doses of
strychnin will be all the medication required, from 3^0^ to o^^o grain
three times daily being sufficient. Troublesome features in the
management of cases in which there is marked involvement of the
palate, the pharynx, and the larynx, consist in the difficulty of
feeding the patient and in the danger of aspirating food and mucus
as a result of the paralysis. The tendency of diphtheritic paralysis
is toward recovery, the time required being usually from four to
eight weeks.
Illustrative Cases. — A bov six years of age had a very mild at-
tack of diphtheria, not of sufficient severity to necessitate his re-
maining in bed. Two weeks after the attack, the time of his coming
under my care, there was marked paralysis of the soft palate and
pharynx which rendered swallowing most difficult. In spite of
energetic treatment with strychnin hypodermatically, the paralysis
soon involved the larynx, the masseters, and the muscles of all the
extremities. Fortunately the heart or diaphragm was not in-
volved. There was a constant flow of saliva which at times entered
the trachea unimpeded, causing severe paroxysms of coughing. In
MULTIPLE NEURITIS 38 1
order to prevent this, the legs and trunk were elevated, the head
being made the most dependent portion of the body. Swallowing
was impossible and he was given by gavage every six hours as
indicated completely peptonized milk, whisky, beaten egg, and
strychnin. The boy made a complete recovery, but it required
three months to accomplish it. In another patient, fifteen months
of age, gavage was practised at six-hour intervals for five days,
when solids could be swallowed.
Gavage (page 134) is but little objected to by children after it has
been used once or twice. It should be employed as soon as it is
shown that enough nourishment cannot be taken by the natural
means. If coughing results in attempts at swallowing, it means
that the larynx is involved and that feeding by the usual means
should not be attempted. Nutrition by means of the bow^el may
be brought into use, but it is not necessary unless there is cardiac
paralysis, in which event the resistance of the patient might enter
as a factor making gavage dangerous. Attempts at swallowing may
be made from time to time. Semisolid substances, such as scraped
beef and soft-boiled egg, will usually be better managed than fluids,
because of the tendency of fluids to pass through the glottis.
MULTIPLE NEURITIS
Neuritis of this nature, aside from that following diphtheria,
is not of as rare occurrence in children as is claimed by some
authors.
The disease may be due to various toxic agents through their
specific action in producing an acute inflammation and degenera-
tion of the peripheral nerves. Among the possible causes are
malaria, the exanthemata, grippe, pneumonia, and typhoid fever.
Lead, phosphorus, arsenic, and alcohol as possible causes are also
to be kept in mind. Lead is a very unusual cause. Arsenic, phos-
phorus, and alcohol, however, are used extensively as therapeutic
agents during child-life, and should always be considered as
possible etiologic factors.
I recently saw two pronounced cases in two brothers following
very severe scarlet fever. Many mild cases of neuritis in children,
following exhaustive diseases with prolonged toxemia, are doubtless
overlooked, the prolonged time required for the return of muscle power
in the arms and legs after such diseases being attributed solely to
muscle weakness. Sensory disturbances in children are not such
prominent symptoms as the neurologist would have us believe, for
the reason, possibly, that he usually sees only the more severe
cases. The mild cases seldom come under his care. I have seen
quite a number of the mild cases in which there were sensory dis-
turbances and a diminished patellar reflex following lobar pneumonia
with high temperature, and also after severe scarlet fever.
382 NERVOUS DISORDERS
Treatment. — The management is largely palliative, there being
a strong tendency to spontaneous recovery in from four to eight
weeks from the onset. Exciting causes, such as the use of alcohol
or some other drug, should, of course, be eUminated, when recovery
usually follows. In those cases due to the toxemia of preceding
disease, time and good care are usually all that will be required to
effect a cure. If pain is present the best means of relief is the use
of heat, the affected limb being bound in thick layers of cotton-
wool. The salicylate of soda and iodid of potash are not to be given
to young children. They produce no appreciable effect, except
possibly a disturbance of digestion and a lessening of the appetite.
Should the pain be sufficient to interfere with sleep, bromid of soda
may be given in doses of from eight to twelve grains, for a child of
from five to ten years of age, at bedtime and repeated but once.
In using hypnotics in children, one drug should not be continued
longer than three days.
Codein is a satisfactory sedative for a child in case the bromid
does not answer. For patients from five to ten years old, from one-
tenth to one-sixth grain may be given at bedtime and repeated once
after an interval of three hours.
As a tonic I know of no better combination of drugs for a child
with neuritis than the following, for a patient from five to ten years
of age :
I^. Strychninse sulphatis gr. |
Extracti ferri pomati gr x
Quininfe bisulphatis 3j
M. et ft. capsulae No. xxx.
Sig. — One after each meal.
If constipation is present or should result from the administration
of iron, from one-third to one-half grain of extract of cascara may
be added to each capsule. The capsules are given for ten days,
followed by cod-liver oil for five days. The oil is given after meals.
At the end of five days the tonic capsules are repeated, to be followed
again by the oil. The patient should have the benefit of an outdoor
life as early as possible. Electricity has not been necessary in my
cases, neither has the use of orthopedic appHances been required.
Massage may be used with advantage after the subsidence of the
acute symptoms. It should be given by one skilled in the work.
FACIAL PARALYSIS
Paralysis of the facial nerve is not of infrequent occurrence in
the young. It may result from forceps pressure at birth or from
pressure exerted by the bony parts of the pelvic outlet. In later
infancy or childhood it may be the result of trauma caused by
operative manipvilations ; it may be of rheumatic origin; it may
be due to cerebellar disease, or to exposure to cold. In one of
CEREBRAL PALSIES 383
my patients it was attributed to sitting by an open window in a
railroad car on a cold day. The nerve in its outward passage through
the fallopian canal may become diseased from the presence of a
purulent otitis media. This is probably the most frequent cause
of the paralysis.
Treatment. The management depends entirely upon the cause
of the paralysis. If due to cerebral disease, but little is to be ex-
pected from treatment. If due to an otitis media, surgical, pro-
cedures, such as establishing a free drainage to the cavity of the
middle ear, to be followed by frequent hot irrigations, should be re-
sorted to. If these are ineffective, the mastoid should be opened and
the cavity drained posteriorly. Where the functional activity of the
nerve is delayed, electricity may be brought into use, as is indicated
below. Cases in which rheumatism is supposed to be a factor should
be given the benefit of anti-rheumatic treatment by the use of the
salicylates (page 467). If the case is due to cold or trauma there is
a strong tendency toward recovery, without treatment. It is diffi-
cult to judge of the value of such a therapeutic measure as elec-
tricity; but the effect of exercising the paralyzed muscles and
stimulating nerve conduction by its use must be of some service.
If the electricity is used, five-minute daily sittings are all that are
necessary, using the faradic current if it produces sufficient reaction.
If not, the interrupted galvanic current should be employed.
CEREBRAL PALSIES
Three types of this affection are recognized by neurologists,
the pre-natal, the birth, and the post-natal.
Concerning the etiology of the pre-natal cases, considerable con-
fusion and varying opinions exist. Degeneracy of the parents, alco-
holism, syphilis, and trauma are supposed to be contributory causes.
I have seen a large number of these undoubtedly pre-natal cases,
and am unable to add anything from the etiologic standpoint. In
several instances the patients have belonged to families of several
children each, the other children being normal, with nothing worthy
of note in the family history and with a normal, uneventful preg-
nancy.
Trauma at birth, whether due to the use of forceps or to com-
pression of the head in a prolonged or abnormal delivery, may result
in meningeal hemorrhages causing an immense number of cases
of cerebral palsy. The obstetrician should always keep in mind
that with him rests the possibility of making a hopeless invalid
or an idiot of the child he is about to deliver. It is fully appre-
ciated that under unusual conditions in obstetric practice certain
risks of head injury must be taken for the sake of the immediate
demands of the mother or the child, but the large number of cases
of cerebral palsy and idiocy which I have seen have impressed
384 NERVOUS DISORDERS
upon me the necessity of treating the child's head during delivery
with the utmost care.
The pre-natal and birth palsies are often paraplegias or diplegias,
and as such show a wide distribution of the lesions. In the post-
natal or the acquired cases there is more apt to be a hemiplegia, the
hemorrhages usually resulting either from blows, falls, convulsions,
or infectious processes. A comparatively trifling injury is some-
times sufficient to produce a hemorrhage.
Illustrative Cases. — A five-year-old boy, a pronounced hemi-
plegic with normal mentality, owes his present condition to a fall
from his baby-carriage to the ground when nine months of age.
The fall was followed by repeated convulsions and hemiplegia.
He came under my care a few days after the fall. The clot was
located, the skull trephined, the blood-clot removed, and the bleed-
ing vessel ligated. The boy today walks well with a brace and
will be able to discard it in a few years; the arm will probably
never be of much service.
Another child, fourteen months of age, was perfectly normal pre-
vious to an acute attack of indigestion with high fever and con-
vulsions. The seizures were repeated several times during the day.
After the third convulsion, it was noticed that there was complete
paralysis of the left side of the face and of the right arm and leg.
The child died thirteen months afterward. His mental condition
never cleared — he remained an idiot until death.
Treatment. — The medical treatment of these cases of paralysis
consists in maintaining a high degree of nutrition. Drugs are of no
service. The management in general in the different types of cases
varies, depending upon the intelligence of the patient, the location
and extent of the paralysis, and the resulting deformity. Braces are
necessary in many cases to prevent contractions and deformities
or to aid in correcting those already present. In some of my cases
of normal or fair mentality marked improvement has followed
daily systematic manipulations and exercises (page 539) under the
management of an expert in this line of work.
A description of operative measures and a discussion of the
cases in which they are applicable m.ay be found in all works on
orthopedics. Systematic exerc'se, massage, and training in the
use of the limbs should be the later management of all operative
cases, in order that the patients may derive the full benefit from
the operation.
IDIOCY
Generally speaking, there are two varieties of idiocy — the pre-
natal and the acquired. There is a very close association between
idiocy and cerebral palsy. Not all idiots suffer from paralysis,
neither are all cases of cerebral palsy idiots; in the majority of
the cases, however, when either is present, the other will be found
IDIOCY 385
associated in a greater or less degree- sometimes the mental, some-
times the physical, infirmity predominating.
The degree of mental impairment varies considerably, being de-
pendent upon the location and severity of the brain lesion, and
whether it is a sclerosis, porencephalus, atrophy, or is due to a lack
of development. There are cases in which there is scarcely sufficient
cerebration for the patient to recognize his parents, and others in
whom it is difficult to determine whether they are within or without
the border-land which we have come to regard as normal. The
diagnosis in most cases can be made at a glance. In two of the
types, both pre-natal, the INIongolian idiot and the cretin, some con-
fusion may exist in differentiation. The latter will be discussed
separately in another section.
Treatment. The management of idiocy is to be considered from
two standpoints: First, as to the physical condition. Under this
heading is included the correction of deformities and the management
as to hygiene and nutrition. The latter, of course, should be the
best obtainable in any given case. The other consideration rests en-
tirely upon the mental aspect of the case and concerns not only the
patient but the family and their immediate interests. It may be said
that, without exception, the place for a mentally defective child is in
an institution which is devoted to the care and teaching of such chil-
dren. He should be placed where much will not be expected, where
he will be associated with others of his kind, where his work and his
play are adjusted and presided over by educated men and women
who have made such conditions the study of their lives. The idiot
has rights. He has a right to live out" his unfortunate life in as
pleasant a manner as possible, and this is better accomplished in
an institution than in any individual home. Here, among other
things, he is taught, according to his capacity to learn, useful occu-
pations, and not a few thus taught become self-supporting. At
rare intervals one is found who possesses remarkable mental traits
along certain Unes, traits which the average normal individual is in-
capable of understanding. I have one such case under my care.
Cases showing a moderate degree of infirmity often become skilled
in handicraft. They execute mechanically with surprising accu-
racy. There have been great geniuses of the past who in some
respects were not considered mentally normal by their contempora-
ries.
It is impossible to form even a fair estimate as to how the men-
tally defective child will develop, with age and suitable instruction
from those who are best able to discover his possibilities. The
placing of these children in public institutions is often strenuously
objected to on sentimental grounds by the poorer elements of society
because of their fears and prejudices against such institutions, and
in consequence the child is kept at home, greatly to his detriment
386 NERVOUS DISORDERS
and to the decided injury of other children in the family. Time
and again I have pleaded with the mothers and fathers of such
children without avail. Few villages throughout the country do
not have an idiot or an idiotic epileptic for school-bovs to taunt
and for school-girls to fear. Most pitiable objects are these human
derelicts, with whom the State does not interfere because they are
"harmless." The prejudices of parents are largely due to the spas-
modic attacks of virtue of the so-called "yellow" press, which peri-
odically writes up, often with illustrations, under glaring headlines,
the abuses in this or that public institution, all of which is solely
in the interest of their circulation. Sooner or later, if he lives, the
idiot of poor parentage will become a public charge, and the better
his condition at the time, the happier he will be.
Parents of means and intelligence will usually place such a child in
one of the many private institutions that are conducted for the care
of defectives; but the objection will often be raised, even by these
people, that in such children there is so little mentality that teach-
ing is useless. This may be true, but if for no other reason, the
child should be removed from the home because of his invariably
pernicious influence on other members of the family. The vicious,
the unclean, and those showing marked moral degeneracy should be
placed in institutions as soon after the fourth year as possible. If
they are to be a public charge, they should be removed from the
home as soon as they arrive at the age Umit which the rules of
the institution require for admission. If the patient is tractable,
he may remain at home until the sixth or seventh year, particu-
larly if there are no other children in the family. In the event
of younger children whose natural tendencies and powers of imita-
tion are always strong, the defective child should be removed as
early as possible.
ERB'S PALSY— OBSTETRIC PARALYSIS
This paralysis is due to an injury of the brachial plexus during
labor. There is little or no power in the muscles supplied by that
portion of the plexus which is the seat of the injury. The arm
hangs limp by the side. The tendency of these cases, whether in-
volving the upper or the lower arm, is toward recovery unless the
nerve lesion is a very grave one.
Treatment. — The atrophy and contractions which develop are de-
termined largely by the extent of the injury and to a lesser degree
by the treatment. During the first three weeks in hfting and hand-
ling the infant the arm should be protected from other injuries such
as may take place in bathing and the other manipulations necessary
in the care of a baby. After this time, massage of the entire arm
and shoulder with lanolin should be practised at least twice a day,
from ten to fifteen minutes at a time. After two weeks, electricity
ANGIONEUROTIC EDEMA 387
may be used for a few minutes each day. If the child can bear it,
the faradic current answers best. But in case there is no response to
faradism, the galvanic current should be used. Under massage and
electricity, the improvement in the arm is often most satisfactory.
It is not well, however, to promise the parents that a normal arm
will be the outcome. I have seen cases in which there was almost
complete restoration of power after it had been entirely lost, while
in others the arm was permanently disabled. The degree of im-
provement is dependent upon several factors, the chief one of which —
the extent of the nerve injury — is in every case uncertain. Opera-
tive measures consisting of grafting and transplanting of the nerve
have been advocated recently by many surgeons. I have had no
experience along this Hne. It would seem to be worthy of trial
when it is demonstrated that the case has made all the improvement
that it would be likely to make with other treatment.
HICCOUGH
Hiccough is a spasm of the diaphragm, usually due to gastric
irritation from the distention of the stomach or intestine with gas
or overloading of the stomach with food. Under such conditions
it is usually of little consequence, and may readily be relieved, if
the attack is prolonged, by an enema of soap-water and a laxative
dose of rhubarb and soda. When it occurs with any grave illness,
it is a symptom of serious import. Hysterical girls will often have
hiccough to quite an alarming degree. The attack usually follows a
period of unusual excitement. In these patients, from twenty to
thirty grains of bromid of soda repeated in from twenty to thirty
minutes will usually control the spasm.
ANGIONEUROTIC EDEMA
Angioneurotic edema is sometimes referred to as "giant hives."
When it occurs in young children, it is most apt to involve the tongue
and hps. When involving the soft parts, the urticarial lesions
often produce an immense amount of swelling. This is particularly
apt to be the case when the tongue and lips are affected. I have
seen the Ups swollen to several times their normal thickness. In
the case of a boy four years of age, the tongue and lower lip were
tremendously swollen. Speaking was impossible and swallowing
difficult. It was supposed that he had been given carbolic acid
or some corrosive poison. These cases usually develop suddenly
and are apt to occasion great alarm. In the case referred to, I
was called thirty miles into the country to see the child in consulta-
tion. Cases have been reported in which the swelling of the tongue
was suflticient to produce suffocation, necessitating incision into the
tongue to reduce the swelling. The cases I have seen have always
been associated with gastro-enteric disturbances. The swelling
388 NERVOUS DISORDERS
usually disappears very rapidly, although not quite as rapidly as it
develops. At the end of twenty-four hours but a slight enlargement
ordinarily remains.
The treatment of this form of urticaria is the same as that of
urticaria in general. The intestinal canal should be kept purged
with saline laxatives and the patient put on a barley and broth
diet for two or three days to relieve the intestinal tract.
For local purposes, where the mucous membrane alone is involved,
a two percent solution of sodium biborate in water, applied on
pieces of old linen, has given the best results. This may be con-
tinued until the swelling becomes greatly reduced or entirely dis-
appears.
SYPHILIS
PRIMARY CONGENITAL SYPHILIS
Treatment. — The only means of treating congenital syphilis in
infants is by the use of mercury, either locally, as by inunctions,
by internal administration, or hypodermatically. The hypodermic
use of the mercurial preparations, such as the albuminate or the
salicylate, are, for obvious reasons, not to be advised in voung
children. The use of the needle would have the effect of sending
the patient to others for treatment, particularly if the case were
seen in out-patient practice. The use of the mercurial ointment
by inunction is a satisfactory method in hospitals and in children's
institutions, where a nurse can make the necessary applications;
in private, however, it is objectionable because of the inunction itself,
which may cause comment, and because of the staining of the skin.
In fact, this treatment cannot well be carried on without other
members of the family becoming acquainted with the nature of the
illness. Definite rules for the management, as regards kissing
and the care of feeding utensils, should be given, so that the other
members of the family may be protected and the real condition
remain unknown. Among the poorer class and in out-patient work
I have found the inunction method unsatisfactory, for the additional
reason that its use is not continued sufficiently, and it is very apt
to be indifferently done. It is often postponed and forgotten,
and as the disease permits of no temporizing, it is for the interest
of the patient that the most effective means possible for its con-
trol be brought into use at the earliest possible moment, and that
is by internal administration.
If the inunction is employed, the mercurial ointment, U. S. P.,
should be used, ten grains being rubbed into the skin daily. The
rubbing should be continued about ten minutes, as this time will
be required for the ointment to be thoroughly rubbed in. The use
of mercury internally gives the best results among all classes. It
is my observation, after the treatment of several hundred of
these cases, that the bichlorid of mercurv in small, frequently re-
peated doses is the best medication. It is given in tablet form.
Its use will have to be continued for a long time, and, as people
are fond of giving drugs, we cater to the weak side of human na-
ture, and thus do the greatest good to our patient.
Mercury — The Dosage and Method of Administration. — For all
infants under one year of age the scheme of medication is the same,
389
390 SYPHILIS
and this one covers the great majority of our cases. Usually they are
seen before the third month. I order the tablet triturate of bi-
chlorid of mercury, ^^q grain. The mother is instructed to give
two tablets daily, morning and night, after feeding. She is told
to give on alternate days an additional tablet, after feeding, until
live are given daily or until the mercury produces loose green
stools. It is comparatively rare that an infant of the tenderest
age cannot take 4V grain daily without inconvenience. If green
stools with a watery tendency result, the increase is temporarily
withheld. It is very rare that the above amount will not ultimately
be taken without inconvenience. Further, the dosage of from
4V to ^V grain in twenty-four hours, in the great majority of the
cases, is all that is necessary to control the disease. If an improve-
ment does not take place after a week's administration, in the ab-
sence of intestinal symptoms, the amount may be increased to 2V
grain in twenty-four hours.
If, after the administration four or five times daily of the bi-
■chlorid in the small doses of 2^^o grain has been continued for
several days, improvement does not take place because of failure
on the part of the child to absorb the drug, inunctions may be used
in addition to the internal treatment. They have been needed,
however, in but few of my cases.
Convalescence. — In a typical case the first sign that the child is
improving will be the fading of the rash. It disappears gradu-
ally, leaving the characteristic staining of the skin, which also clears
up in a few weeks. Coincident with the fading of the rash, the coryza
becomes less pronounced and the hoarse voice becomes clearer. If
there has been an enlargement of the liver and spleen, after a few
weeks of treatment, they will be noticed to have diminished in size.
The child gains in weight, and if the case progresses satisfactorily,
soon looks like a normal baby. This is not always the happy out-
come, however. Occasionally we have cases which apply for treat-
ment with the vital powers greatly depressed or wath so intense an
infection that treatment is of no avail, and they die in a few wrecks
from marasmus.
The enlargement of the epitrochlear glands is, in my experience,
the last sign to disappear, and in many cases these glands, though
reduced in size, always remain enlarged without any other persis-
tent evidence of the disease.
Later Treatment. — What should be the further management
of such a so-called "cured " case? Are we justified in discharging
the patient and allowing him to pass from under our observation?
My experience proves the contrary, nor can I state that congenital
syphilis is ever cured. I have seen many cases, how^ever, that were
apparently cured, and which showed no signs whatsoever of the
disease. Against my advice, they have passed from under observa-
TARDY HEREDITARY SYPHII^IS 39I
tion for two, three, or four years, and then reappeared for treatment
because of the presentation of some manifestation of a tertiary
lesion — a so-called "tardy hereditary syphilis."
My instructions to the parents or guardians of my syphiUtic
patients apparently cured, are to bring them to me once in three
months for examination. If they remove to such a distance that
this is not possible, then I ask them to take the child at the speci-
fied time to some other physician and explain to him the nature
of the previous illness. For such patients as return, for the first
two or three years, I often advise a course of bichlorid for one
month out of every three. I do not feel that it is necessary for such
a child to show positive specific signs in order to receive this inter-
rupted treatment ; if he shows retarded growth or anemia or a his-
tory is given of his lack of resistance to disease he should unquestion-
ably have the advantage of the treatment. In such a case I find
that the improvement is much more satisfactory when some prepa-
ration of mercury is used to supplement whatever restorative treat-
ment may be suggested.
TARDY HEREDITARY SYPHILIS
By tardy hereditary syphilis it is understood that, for some
reason, the infection failed to manifest its presence with any appre-
ciable severity until the period of childhood was reached.
In its selection of anatomic sites for its development, and in
the nature of the lesion, it closely resembles the tertiary form in
the adult. The eyes, the bones, and the nervous system are par-
ticularly apt to be involved. The development of the Hutchinson
teeth and the involvement of the shafts of the long bones, resulting
in a periostitis, are its most frequent manifestations, these together
with general malnutrition, are almost always associated with the
disease in childhood.
Treatment. — As in the treatment of tertiary syphiUs in the adult,
so likewise in the treatment of the late hereditary form in children,
the iodids play an important part. Much better results, however, are
obtained with the so-called "mixed treatment." The iodids alone
are not sufficient to give us our best results, and the results wath
mercury alone are not so prompt and satisfactory as when the two
drugs are combined. For an average case of periostitis involving
the anterior portion of the tibia in a child four years of age, from
gig- to 2V grain of bichlorid of mercury should be given daily, com-
bined with sufficient iodid of potash to produce the characteristic
coryza. This may necessitate the giving of from twelve to twenty
grains daily, as children vary greatly in their susceptibility to the
drug. The mercury and the iodid of potash should not be given
in one mixture, as the combination is most disagreeable to the taste.
It is far better to give the bichlorid in the form of tablet triturates.
392 SYPHILIS
The iodid of potash is best given in a saturated solution, one drop
of which represents one grain of the drug. This is best taken when
dropped into milk after meals. Beneficial results from the treat-
ment will usually be apparent in a few days. If there is a periostitis,
the pain will be the first symptom to disappear.
The administration of the iodid of potash should always be
interrupted, chiefly because of its possibilities of deranging the
child's digestion. I usually give it for ten days, followed by a rest
of five days, when it is again resumed. Proper nutrition in these
cases is a most important factor in their management. If the
iodid is given to the point of tolerance, its omission for a few days
will not be noticed. The mercury is given for weeks continuously in
doses of from -^^ to ^V grain three times a day, graduated according
to the age. Later, when the progress of the case shows that the
disease is under control, the two drugs should be given alternately,
for ten days each. How long this treatment should be continued
must be determined by each individual case. Cases which are
apparently cured should be instructed to report to the physician
every three months. I frequently advise a course of treatment for
three or four weeks, two or three times a year. A sufficient excuse
for such action may be the condition of the child, who may show
a tendency toward slow growth and improper nutrition. The pa-
tient should be kept under observation for years. He should be
seen at stated intervals until the adult period is reached, when the
nature of the trouble should be explained to him. The disease from
which the child is suffering should always be made plain to parents,
or at least to one of them, in order that the patient may not be
allowed to pass from under medical observation in ignorance of his
true condition.
TARDY MALNUTRITION OF SYPHILITIC ORIGIN
The possible manifestations of syphilis in the young, as in the
adult, are many. In children, not the least interesting and impor-
tant are the cases in which late malnutrition is the only evidence
of the syphilitic infection. The patients are usually thin, some-
times sallow, sometimes pale, with little or no adipose tissue. They
are almost always undersized, as regards height, always under-
weight, the appetite is poor, and they have but little endurance
and correspondingly little resistance. The cases seen by me were
between three and ten years of age. When two such children are
seen in a family, in which both parents are robust, it is a strong
indication that they are suffering from the results of a remote syphi-
litic infection in one of the parents. The physical examination
may prove nothing definitely.
Cases of late malnutrition, non-syphihtic in character, due to
poor hvgiene and faulty feeding, may present symptoms identical
TARDY MALNUTRITION OF SYPHILITIC ORIGIN 393
with the above, so that while the two conditions cannot be differ-
entiated by the cUnical signs, there may be sufficient grounds for
suspicion to warrant us in questioning the father, when the history of
a primary sore with perhaps secondary lesions may be elicited.
There may have been prolonged treatment with a subsidence of all
the symptoms, and the patient may have been pronounced cured
and told that it was safe to marry. Many times have I heard this
story when the evidence of transmission was before me in the form
of a typical case of congenital syphilis.
Treatment. — Treatment of tardy malnutrition of syphiUtic origin
by the supportive and restorative methods used in the non-syphilitic
malnutrition cases is without avail. (See Tardy Malnutrition, page
158.) These patients require mercury either alone or combined
with the iodids. To the usual methods of treatment with iron,
cod-Uver oil, baths, and massage, there will be but httle response,
but add bichlorid of mercury or the iodid of potash and the case
improves, slowly to be sure, but the improvement is invariable.
In the management of such a case the child should be given the
advantage of an outdoor life with free ventilation of the sleeping-
room at night. The food should be highly nutritious, containing
a large amount of proteid. Eggs, meat, milk, and the high-proteid
cereals, such as oatmeal, are the most valuable. The dried legumes,
— peas, beans, and lentils, — given in the form of purees, are a valu-
able addition to the diet. Salt baths at bedtime (page 31) during
the entire year, followed by oil inunctions during the cooler months,
are valuable in restoring the child to a vigorous condition. As
these children are almost always anemic, it may be well to combine
the bichlorid of mercury with nux vomica and quinin. For a child
from five to ten years of age, the following prescription has been
used with marked benefit :
I^. Hydrargyri bichloridi gr. ss
Tincturae nucis vomicae gtt. xc
Extracti ferri pomati gr. x
Quininae bisulphatis 5j
M. div. et ft. capsulae No. xxx.
Sig. — One capsule after each meal.
This is given for ten days, alternating with bichlorid of mercury
in tablet form — gV grain three times daily after meals. During
the ten days when the bichlorid is given alone, maltine and cod-
liver oil may be given — one dessertspoonful three times a day after
meals. Every ten days the medication other than the bichlorid
is changed. The latter should be given continuously. In these
cases, iodid of potash is not to be given early in the treatment,
for the reason that the appetite is usually poor or indifferent, and the
administration of the drug at this time might further decrease the
desire for food. The iodid of iron may be used in doses of from
394 SYPHILIS
ten to fifteen drops, three times daily, should the physician desire
to change the form in which the iron is administered.
Prolonged treatment will usually be required. These cases
should be kept under close observation for at least two years, or
until they arrive at adolescence, when they should be made ac-
quainted with the nature of the disease. During the entire growing
period the administration of mercury during one month out of every
three, or possibly every six, depending upon the child's condition,
will insure better growth and a more vigorous development both
physically and mentally.
DEFORMITIES
INGUINAL HERNIA
Inguinal hernia is of rare occurrence in girls but comparatively
frequent in boys. Predisposing causes, other than the anatomic,
are whooping-cough and colic. I have seen several cases due to
each of these conditions. In a like manner, constipation or difficult
micturition may be a cause.
Reduction. — The reduction of an inguinal hernia in an infant
may be difficult because of the distended abdomen and the abdom-
inal pressure exerted by crying. It is best accomplished while the
child, with legs and buttocks considerably elevated, is held by
an attendant. Gentle manipulation with the thumb, index and
second finger, which grasp the lower portion of the tumor, and
pressure toward the ring, are usually successful. If reduction is
not readilv effected, it is better to anesthetize the child, after which
it can usually be done with comparative ease.
Treatment. — The treatment of inguinal hernia in infants and
young children is by mechanical means or by operation. In in-
fants under one year of age operation is rarely required. The
most satisfactory measure in my hands for treating inguinal hernia
has been by the use of a hard-rubber, cross-body truss. The pad
should be but slightly convex. A hard-rubber truss is readily
cleaned, and the cross-body truss keeps its position in young infants
better than does any other. If there is a double hernia, the hard-
rubber truss or the Hood frame truss, made of hard rubber, may
be used. Measurement for the truss is taken around the hips on
a plane with the hernia. The child should wear the truss day and
night. By placing the truss in hot water for a few seconds or warming
it slightly before the fire, it can readily be bent so as to fit the patient
comfortably. When the truss is removed for the purpose of cleansing,
which should be done twice a day, a helper should be at hand to
support the ring so that there shall be no descent of the hernia.
One descent may mean that several weeks' care has been brought
to naught. It is well to keep the skin under the truss well pow-
dered when first applied, and the child is often made more com-
fortable by placing absorbent cotton between the skin and the hard
rubber.
As the child grows, the truss will have to be changed frequently.
Its use should be continued for at least one year after the last descent
of the hernia. Operation is required when the hernia becomes
395
396 DEFORMITIES
strangulated, and it is always to be advised in older children if a
cure is not effected after two years' treatment by truss. Many of my
cases have entirely recovered in less than six months.
UMBILICAL HERNIA
Umbilical hernia may be either congenital or acquired. However,
nearly all cases may be said to be congenital, since the hernia is
due, either to a failure in the closure of the ventral laminae, or to a
defective development of the parts at the umbilical opening, which
give way under pressure, such as straining in whooping-cough or
in colic.
The hernia may vary in diameter from one-fourth inch to one
inch and may protrude as much as an inch and one-half. Occa-
sionally cases are seen in which there is an associated ventral
hernia immediately above the umbilical. Ten percent of dispen-
sary cases under six months of age have umbilical hernia?, and it
Fig. 42.— Umbilical Hernia Reduced and Adhesive Plaster Applied.
is by no means rare among the better classes. It usually makes
its appearance during the early months of Ufe.
Treatment. — The treatment is entirely mechanical and consists
in reducing the hernia and applying sufficient pressure to prevent
its recurrence. By far the most effective means is bringing together
over the umbilicus (Fig. 42) the two lateral folds of the skin, so
that they meet in the median line. The two folds of skin thus
placed form a spHnt. Over this is placed a strip of Z. O. adhesive
plaster one or tw^o inches wide, the length depending upon the size
of the child. Usually a strip from four to six inches long is re-
quired. I have found this method much more satisfactorv than any
other, as it is followed by a more rapid cure.
The objection to the use of the covered button or any other
form of pad is that unless it is very large, it is apt to make strong
sriivjA itii'iDA 397
pressure upon IIk- abdominal optiiinj;, and wliik- it rcdnci'S tlir luTuia,
tin- pressure fxcrtcd upon the abdominal rinj^pri-vfuts its rapid closuri'.
Not only may it thus act nuchanically in pri-vcnlinj; tlu- closinj; in
of the abdominal wall, l)ut, tlirouj^h intcrfcivncf with the circulation,
the nutrition of the musclts is intcrfcrc-d with and tlic weakness
persists. Umbilical trusses and bandajjes have been used n-peatedly
and all have been hopi-less failures, and foi oiu- reason chielly the
dilTiculty of keeping tluin in position. ,\ii\ inlilli^Hiit mother
or nurse can be tau};hl in a few miiuites how to apph the i)laster
as above suSJi^'Sted. The child may be ballud with the plaster
in position. Ordinarily, it is best (o a])ply a fresh piece every lifth
day. Irritation of the skin under the plaster sometimes occurs.
If there is a tc-ndency to excoriation or ifdness of the skin, the
folds can be made at right anp;les to those previously luadc and tln'
plaster aj^ain apj)lied at right angles to tlu' folds. Hy so doing, the
excoriated skin reiuains uncovered. If the hernia is not particularly
large and if the case is seen during the lirst, second, oi tliird montli
of life, a cure can be expected in from three to six nionllis. The
yoiuiger the child, the more rapid will be the cure. Repeatedly,
when treatment was begun within the lirst six weeks, 1 have seen
a large hernia completely cured in a few months. In not one of
my cases has operation been necessary.
VENTRAL HERNIA
This form of hernia is of congenital origin and is only occasionally
seen in infants. It may be associated with lunbilical hernia or it
may occur independently. It may be due to a failure of the recti
to unite in the median line or it may be due to a weakness or an
imperfect development of the fibers of i itlui iiuiselc.
There is rarely any great i)rotrusion of the iilxlomin.d contents,
as in the other forms of hernia. Usually a ventral hernia manifests
itself in a fullness or a distinctly localized elevation of the skin over
the site of the absent or weakened nuiscle tissue in (he abdominal
walls.
The application of a four inch strip of Z. O. adhesive plaster
one and one- half to two inches wide-, placed Hat on the skin over
tlu- hernia, is all that will be recpiired. The support thus furnished
will have to be continued for several montlis. Operation may
sometimes be necessary, but it has not l)een reepiired in mv cases.
SPINA BIFIDA
The results of treatment of spina bifida, regardless of its type
or the method employed, will scarcely warrant us in promising
parents much in the way of improvement. In my hands the injec-
tion of iodin has not been of any value. The pressure treatment is
unsatisfactory. Surgery promises better results than does any
398 DEFORMITIES
other treatment. Operative measures are fully described in works
of surgery and the results are sometimes brilliant. Operations,
however, are not without immediate danger, for in a great ma-
jority of the cases portions of the cord are within the sac, the
excision of which may result in permanent paralysis and deformity.
It is the duty of the family physician to see that the tumor is care-
fully protected and kept clean and the child properly nourished
until such time as operation by excision or otherwise is thought
advisable, which ordinarily is not until the child is one year of age.
HARELIP
The time for the operation for harelip depends, within certain
limits, upon the condition of the child. Some surgeons prefer to
operate very early and others when the child is several months
old. Ordinarily the operation should not be performed before the
patient is one month old or delayed after the fourth month, if the
child's condition and the season of the year permit. Operations
on young children should not take place during the hot months
because of the lack of resistance on the part of a young infant to
the shock of an operation, and because of the dangers of gastro-
enteric complications, the latter being considerable. The matter
of feeding need not hasten the operation if other factors in the case
are unfavorable for it. The child with harelip may be successfully
fed by gavage (page 134) for an indefinite period.
HEMATOMA OF THE STERNOCLEIDOMASTOID
The tumor which is formed in a portion of this muscle is
caused bv an injury during birth, and consists of a rupture of the
muscle-fibers and of the blood-vessels. The tumor may be small,
not larger than a filbert, or it may involve a considerable part of
the muscle structure. When much of the muscle is included in the
tumor, the head of the patient is held in a constrained position with
the face directed toward the affected side. The tendency of these
cases is to recover without treatment, but it has seemed to me, from
an observation of saveral cases where it was employed, that the
absorption of the tumor was hastened by massage, which should be
practised for fifteen minutes three times a day. A moderate stretch-
ing of the muscle by forcible rotation of the head toward the
unaffected side and upward appeared to be of benefit in a few cases,
the movements being practised at the same time as the massage.
CLEFT PALATE
Cleft palate may involve either the hard or soft palate, or both.
The time for operation, and the nutrition until such time arrives,
are all that concern us. Operation should not take place during the
first year, and is better performed between the first and the second
CLEFT PALATE
399
years, but not later than the second, as the result is much more satis-
factory than if left to a later age. The feeding of the patient is
usually considerably interfered with. The child is rarely able to
take the bottle, and the various devices for the formation of an
artificial hard palate are usually failures. Sucking on the bottle or
nipple is, of course, out of the question. A spoon or a large medi-
cine-dropper may be employed in feeding, but their use is tiresome
both for the attendant and the child. By far the best method of
feeding in these cases is by gavage (page 134). The nutrition of the
child may thus be maintained for months, and with results quite as
good as by natural methods. I have a child ten months of age
under my care at the present time who has always been fed by
gavage at intervals suitable for his age, and his development has
been perfect.
DISEASES OF THE SKIN
ECZEMA
When one considers the sensitive nature of the skin and its
constant exposure to all sorts of irritating influences it cannot be
surprising that skin affections are more frequently seen in infants
than are any other ailments; and when one recognizes in the skin
an organ of absorption, secretion, and excretion, the importance
of a careful study of its lesions will be self-evident. Inasmuch,
therefore, as what is known as eczema is characterized both by
acute and chronic inflammations of the skin, the fact that in its
different forms it comprises a large percentage of the skin diseases
of young children is readily understood. From an etiologic stand-
point, eczema in children may be divided primarily into two classes:
those forms due to causes operating from within — systemic condi-
tions; and those due to causes operating from without — local irri-
tations of whatever nature.
Manifestations. The manifestations of eczema are subject to
most sudden changes, an apparently normal skin today developing a
weeping eczema tomorrow, while a few days later the skin may again
be clear. It is difiicult and unnecessary in children to attempt
any such differentiation of the various types of eczema as is laid
down in works on dermatology ; and indeed such a differentiation
is difficult, for the reason that in children eczema is not confined
to the special adult types, but rather to various combinations of
lesions, — every variety of papule, vesicle, pustule, and fissure being
often seen in one patient on a surface area of only a few square
inches. Infections of the involved areas resulting in pustules and
furuncles are more common in children than in adults, because
of the ready inoculation and transmission of bacteria through
manipulation and scratching, and because of the diminished re-
sistance offered by the child to pyogenic organisms.
Cases Originating from Within. — Such cases are by far the more
frequent and the more troublesome. The most susceptible age is
from one to twelve months. While cases which have developed
during the earlier months may be carried over into the second or
into the third year, it is comparatively rare for this to happen,
as it is also rare for cases to develop after the nursing age. At
this early period the inflammatory process may be limited to a
round weeping spot on each cheek, or it may involve all the flexor
surfaces, or it may cover larger portions of the skin surface and
show all the clinical phases of the disease. The physical condition
400
ECZEMA
401
of the child exerts no influence upon the development or persistence
of the eczema.
Some of my healthiest nursing babies— those who made most
satisfactory progress and were well in every other respect — were
sufferers from eczema until the nursing period was over or until
nursing was discontinued and other food given. In fact, the ma-
jority of my cases, both breast-fed and bottle-fed, have been in
children whose condition was otherwise satisfactory. There were
others, to be sure, who suffered from malnutrition or who were
difficult feeding cases. In some of these the eczema was, doubtless,
a factor in causing the malnutrition ; for on account of the excessive
itching, restlessness, and sleeplessness, the child's strength had
become so markedly reduced that malnutrition was just as Uable
to be a result as a cause of the eczema. Athreptic and malnutrition
children are very apt to be free from eczema of an acute inflamma-
tory type ; the cases we are considering, however, are due to intes-
tinal indigestion and faulty metabolism of such a nature as not to
interfere with nutrition. We know from cUnical experience that
no one cause is operative in all cases, and we know also that our
management, to be effective, must be directed toward the in-
testinal tract and the liver.
Several of my patients who have been sufferers from eczema
in babyhood have in later life developed some recurrent illness,
such as bronchitis, asthma, or recurrent vomiting. Not a few of
these persistent eczemas in infants are associated with gout and
rheumatism. In out-patient work a great many cases of acute
eczema are seen, and they are not infrequent in office pediatric work.
Not all cases are relieved by treatment, but usually some way may
be found to relieve most of them. In a few, regardless of treatment,
the eczema persists in a less aggravated form, until the child is
weaned or until milk-feeding can in a measure be discontinued.
Treatment. ^In the breast-fed, a proper regulation of the nurs-
ing as regards time and quantity may be sufficient. The relief of
the constipation of the mother is all that is required in some eczem-
atous, breast-fed infants. The eczema which is due to high fat or
high proteid, or both, in the breast-fed may be relieved by regulating
the diet of the mother (page 69) and by insisting upon reasonable
exercise. If the child is thriving, making a satisfactory gain in
weight, the nursing should never be discontinued because of the ec-
zema. If the mother or wet-nurse has been indulging in too rich
food, drinking beer, tea, or coffee in excess, they should be discon-
tinued and a very plain diet substituted. Two grains of bicarbonate
of soda given in two drams of water before each nursing is often of
service. Of late, in those cases of eczema in which the urine has
shown marked acidity I have given with apparent b2nefit two grains
of citrate of potash, three times daily.
26
402 DISEASES OF THE SKIN
In the bottle-fed, the correction of errors in feeding is easier,
and, as a whole, such cases are more satisfactory to treat than are
the breast-fed cases. The eczema may respond to the treatment
of constipation if it exists. It is impossible in a given case to tell
whether the feeding as a whole is a cause of the trouble, or some
one of the nutritional elements is at fault. My usual way in the
bottle-fed is to give a food upon which the child may be ex-
pected to thrive. If the eczema is pronounced, the sugar, for a
week, is reduced perhaps to 4 percent. When this produces no
effect, the 6 or 7 percent of sugar is resumed and the fat or pro-
teid reduced. Working in this way, by a process of exclusion,
I have discovered which element in the food was apparently at
fault and the eczema has responded to its correction. The food
should never be so manipulated that the infant will not thrive.
Illustrative Cases. — One of my patients, a baby otherwise
normal, had the most pronounced general eczema that I have ever
seen, the entire skin surface being involved. For seven months —
until he was past one year of age — I was unable to give this pa-
tient more than i percent of fat. An increase to 1.5 percent of
fat would be followed in one-half hour by an inflammation and
redness of the skin. In another case almost as severe — one which
I saw at the ninth month — I was unable to give cow's milk in any
form. The condition was so aggravated that I discontinued en-
tirely the fresh cow's milk and put the child on condensed milk,
when the skin cleared promptly without any other treatment what-
ever. About six weeks later fresh cow's milk was again tried in
small quantities, with a prompt return of the eczema. At different
intervals the cow's milk was given for one or two feedings daily,
but we were always obliged to discontinue it because of the signs
of the old trouble which immediately appeared after two or three
cow's-milk feedings had been given.
In these obstinate cases as the urine is usually very acid, and
a deposit of urates will be found on the napkin, I invariably give
bicarbonate of soda, one grain to one ounce of food, or two grains
of citrate of potash three or four times daily.
Local Treatment. — The local treatment in the cases of internal
origin is very unsatisfactory, and all that can be accomplished is to
relieve the itching and make the child more comfortable. It may
safely be said that in the treatment of eczema in infants more harm
than good usually results from local measures. As a rule, too strong
lotions and ointments are used, which, while they may not increase
the irritation, produce enough to retard recovery.
When the face is involved, showing a bright red or weeping
surface, the application of bassorin paste usually gives relief. The
paste dries on the parts and forms a firm protective dressing. The
oil of cade — one-half dram to one dram, to one ounce of collodion —
ECZIvMA 403
may be used. If there is a very acute infection, fifteen minims
of the oil of cade to an ounce of either bassorin paste or collodion is
the proper proportion. The face should not be washed nor the appli-
cations removed. As it peels off it should be freshly applied. The
bassorin paste ' will not bear the addition of liquids in any consider-
able amount, but the oxid of zinc may be combined with it, as may
also ichthyol and tar in small amounts. Ointments applied to
the face, unprotected, are soon rubbed off and soil the clothing.
The use of a mask is recommended in some out-patient and hospital
cases, but strongly objected to in private practice. When an oint-
ment can be applied under a mask, or when it is to be used on other
parts of the body where it may be bound upon the parts, the pre-
parations of tar afford greater relief than does any other application.
An ointment composed of the unguentem picis, U. S. P., one part,
with imguentem aquae rosae, from four to six parts, — the strength
used depending upon the irritability of the skin, — may be applied
at least morning and evening. It should be thickly spread upon old
linen and bound firmly but gently to the parts. If the existing irrita-
tion is at all increased by the appHcation, it should be weakened
by a reduction in the amount of tar used. In spite of the eczema
these infants must be bathed. The bran or soda bath (page 31)
may be used, care being taken to avoid too much friction of the
skin.
Eczema Due to Irritation from Without. — Eczema due to irri-
tation from without is not unusual with sensitive skins. It may be
caused by strong soaps, by vigorous rubbing, by irritating clothing,
such as woolens, etc., or it may result from counter-irritation applied
because of some respiratory disorder. Obviously the management
of these cases depends upon the removal of the source of irritation.
In some of my cases where woolens cannot be worn I advise that
the linen mesh be substituted; in others that the garment which
comes in contact with the skin be lined with thin soft linen.
Eczema Intertrigo. — Eczema intertrigo is a result of maceration
of the skin, where two skin surfaces are in constant apposition.
It is most frequently seen in the skin-folds of the neck, the groin,
under the arms, and on the flexor surfaces at the elbow-joint. At
first there is usually a simple erythema, which if neglected
develops into a characteristic eczema. The treatment consists
in separating the opposed surfaces by pledgets of cotton freely
dusted with equal parts of powdered starch and oxid of zinc. The
cotton should be removed as soon as it becomes moist and fresh ap-
plications made. Linen or gauze may be used in the same way.
Usually this treatment promptly relieves the condition.
A similar maceration of the skin may occur when the genitals
and the skin over the inner portion of the thighs, the buttocks,
' Manufactured by Lehn and Fink, New York.
404 DISEASES OF THE SKIN
and the lower abdomen are allowed to remain wet with decom-
posing urine. With very few exceptions these cases are due to
neglect. Athreptic and malnutrition infants furnish many of the
cases. In a few infants well cared for, intertrigo may develop.
In these, it may be explained by a very acid urine or it may be
one of the manifestations of seborrheic eczema (page 405).
The treatment, with the exception of the seborrheic type, con-
sists in neutralizing the urine by the use of bicarbonate of soda,
— two grains three times daily, — by protecting the skin surfaces,
and, by attention to the napkin, preventing irritation from the dis-
charges. Dusting-powders are of very little use here. The method
which has been most satisfactory, and which I have followed
with success for years even in the most unpromising subjects, is
as follows: The mother or nurse is instructed to keep close watch
of the napkin and change it as soon as it is soiled and not to reapply
it until it has been washed. She is further instructed to prepare
pieces of gauze or old linen of such shape and size as to cover the
denuded surfaces. On these slips of linen she is directed to spread
zinc ointment most plentifully. The dressing is then applied to the
parts and is to be changed several times daily. Over this dressing
the napkin is placed. The urine, which is chiefly at fault, is pre-
vented by the ointment dressings from coming in contact with the
skin, the treatment being solely protective. At the same time
a quantity of absorbent cotton is placed next to the genitals so as
to absorb the urine as it is passed and thus prevent its general dis-
tribution over the parts. If the ointment is simply spread over
the skin and the napkin applied, it will soon be absorbed by the
napkin and be of no service. When the case is well advanced
toward recovery, scrupulous cleanliness and a dusting-powder com-
posed of equal parts of powdered starch and oxid of zinc will usually
be all that is required.
Chronic Eczema in Older Children. — A form of chronic eczema
of comparatively frequent occurrence in out-patient cases remains
to be described. Some writers refer to it as a "neurotic eczema "
and others as a "reflex eczema." The predominating lesions are
papules. The first local manifestations are papules, and they
remain papules unless other changes are produced by scratching.
Oftentimes the papule is tipped with a black speck which repre-
sents dried blood and dirt — a result of scratching. A large portion
of the skin surface may be covered by the eruption or it may be
localized on the arms or thighs. Itching is a troublesome feature
of these cases; in some it is almost unbearable, and the patient
is often presented with the skin torn and bleeding. The disease is
without doubt due to some low form of intestinal toxemia. Often
the patient suffers from constipation; he may have a large, dis-
tended abdomen and not infrequently quite offensive stools.
ECZEMA 405
Treatment. — The treatment consists largely of internal measures.
The best initial internal medication for this condition is calomel or
rhubarb and soda, not sufficient to produce purging, although at the
outset a purge may be of advantage. For a child from four to six
years of age, from two to four grains of rhubarb with six grains of bicar-
bonate of soda should be given twice daily between meals, for two,
three, or more weeks; sufficient should be given to produce one
or, better, two soft movements daily. The rhubarb and soda may
be given in two drams of a solution of equal parts of aromatic syrup of
rhubarb and water. Every fourth night at bedtime one-fourth grain
of calomel is given. The diet suitable for the child's age (pp. 129-
132) may be given. It generally means a radical change in the
feeding methods, as the records usually show that these children have
been very badly fed. Nothing is to be given between meals. The
best local treatment is an ointment of salicylic acid or tar, either
separately or combined. If there is an acute dermatitis as a result
of scratching, only a weak solution of salicylic acid should be used,
or it may be wise to omit it entirely until the dermatitis has subsided,
using instead the plain zinc ointment, U. S. P., with the addition of
menthol, as follows:
I^. Mentholi gr. x
Unguenti zinci oxidi 5j
After the acute dermatitis has subsided the following prescription
answers well:
I^. Acidi salicylatis gr. x
Unguenti picis U. S. P 5ss
Unguenti aquae rosae q. s. ad 5ij
The ointment should be used twice daily, bound to the parts
so as completely to cover the surfaces, thereby getting the full
benefit of the treatment and at the same time protecting the skin
from further irritation by scratching. The cases are usually obsti-
nate and treatment will have to be continued from three to six weeks.
In those children who have been suffering from this form of eczema
for a long time and who show extensive lesions, two or three months
may be required to complete a cure.
Seborrheic Eczema. — This form of eczema is due to an excessive
secretion of the sebaceous glands which is dependent upon a func-
tional derangement, probably inflammatory in character. It is
believed by some dermatologists that the disease is dependent upon
a specific infection.
Seborrhea Capitis {Milk Crust). — The form in which it is most
frequently seen in children develops on the head in the form of
thick, dirty, yellow crusts, commonly known as "milk crust." In
mild cases the crusts may be isolated or there may be one large
4o6 DISEASES OF THE SKIN
patch with several surrounding smaller areas. In some cases the
exudation is thick and uniform and covers the vertex of the head
like a mask. The exudation consists of sebum, dirt, and desqua-
mated epithelium.
Treatment. — The first step in the treatment is to remove
the crusts. The hair should be cut very short. If only a few areas
are involved, anointing the parts wuth vaselin several times daily
will soften them so that they may be removed. If the crust is thick
and extensive it is best to soften it with sterilized olive oil, which
is appHed on gauze or old linen. The material used, saturated with
the oil, is held in place by a cap made of cheese-cloth. If the dressing
is applied at bedtime the crusts may often be removed the following
morning. In cases in which the exudation has existed for a long
time and is very hard, it may require two or three days, with frequent
fresh applications of the oil, to soften it sufficiently for removal
without injury to the skin. When thoroughly softened it should
be washed off with castile soap and warm water. After the crusts
are removed, a reddish, slightly inflamed skin will usually be found
underneath. To this is applied an ointment of resorcin and vaselin,
twenty grains to the ounce. The ointment is spread on linen or lint
and applied to the parts, the gauze cap being worn to hold it in
position. In many cases this treatment, used only at night, will be
sufficient ; only the most aggravated cases need wear the cap during
the day. A few applications of the ointment to the parts during the
day will usually be all that is needed. A few days' treatment will
often relieve the worst cases of seborrhea capitis, after the scalp
has been freed from crusts. I have yet to see a case which did
not respond when this treatment was properly carried out. It is
to be remembered, however, that in these cases there is a tendency
for the exudation to return. Mothers and nurses are instructed
to keep the ointment in the nursery for use upon the first appear-
ance of the exudation. In children, seborrheic eczema, according to
my observation, is comparatively unusual in other portions of the
body. Associated with the seborrhea of the scalp, the forehead
and face may be involved. In these situations also resorcin is
useful, but must be used in much weaker strength — from 0.5 to i
percent.
Sebonhca lutcrtn'go. — At rare intervals cases of intertrigo are
encountered upon which no impression whatever is made by the
methods of treatment suggested on page 404. Several years ago
Dr. George T. Elliot, of New York, called my attention to the fact
that these cases were of seborrheic origin, and that a change from
the ordinary treatment to that ordinarily used for seborrheic ec-
zema would prove his contention. In the cases in question, and
in those that I have seen since, the point made by him has been
confirmed by the treatment. Cases of seborrhea intertrigo are
urticaria; hives; nettle-rash 407
generally associated with seborrhea elsewhere, usually of the head,
and show erythema, a tendency to dryness of the skin, and des-
quamation.
The treatment in this form of intertrigo consists in cleanhncss
and diet, as mentioned under Intertrigo, page 404. In addition to the
usual means, from 0.5 to i percent of resorcin should be added to
the ungt. zinci oxidi which is used as a dressing. Seborrheic eczema
is not as difficult of management as the other forms of eczema in
children, but there is a great tendency for it to return, particularly
in cases of low vitality.
URTICARIA; HIVES; NETTLE-RASH
Urticaria is characterized by the sudden appearance and dis-
appearance on the skin surface of wheals of vasomotor origin. The
wheals, which are associated with intense itching and burning, are
of different varieties and subside without desquamation. They
vary considerably in size and shape, which fact has given rise to
a differentiation into types for purposes of diagnosis. For our
purpose a division has to be made from the etiologic standpoint
only.
Urticaria may be due to agencies operating either from without or
from within. An agency operating from without may be an irritant
of almost any nature — the bites of insects, clothing which may
irritate the skin, or clothing which is too tight. Contact with
different plants may also produce the wheals. Such causes as these,
however, are factors in but comparatively few cases. The manage-
ment, obviously, is the removal of the source of irritation and the
apphcation of a simple ointment, such as one composed of ten
grains of menthol to one ounce of cold-cream, or the parts may
be bathed with a i percent carbolic solution.
Irritation arising from internal sources is the cause of the condition
in at least 95 percent of the cases. The use of certain drugs may
furnish sufficient irritation to cause the outbreak. I have in not a
few instances seen hives due to quinin, arsenic, or antipyrin. The
administration of diphtheritic antitoxin produces urticaria in from
15 to 20 percent of the cases. Certain articles of food, such as
strawberries, tomatoes, oatmeal, and buckwheat, invariably cause
urticaria in some children. Digestive disturbances of any'nature,
whether acute or chronic in character, may cause urticaria. In
an attack, therefore, where no external cause can be discovered,
and where drug idiosyncrasies can be ehminated, it is fair to assume
that the source is the intestinal canal. A safe procedure is to give
a full dose of castor oil — two to four teaspoonfuls — or one grain
of calomel in divided doses, followed the next morning by the
citrate or the milk of magnesia. At the same time, the diet, re-
gardless of the age, should be reduced to broths and gruels, to
408 DISEASES OF THE SKIN
which toast or dried bread may be added if the patient has been
accustomed to it. Milk should not be given. A laxative, a reduced
diet, and the application of the menthol ointment already re-
ferred to will usually be all that is required. In those that persist
in spite of these measures, which include the antitoxin cases, sali-
cylate of soda (wintergreen) will bring them to a termination
sooner than will any other measure. For a child three years of
age two grains of the salicylate of soda may be given every two
hours, with four grains of the bicarbonate of soda — five doses being
given in twenty-four hours. After this age from three to four
grains of the salicylate may be given at a dose — from twelve to
twenty-four grains in twenty-four hours. Certain children appear
to be predisposed to urticaria and give a history of having had
several attacks. Children who suffer from persistent intestinal in-
digestion are very liable to recurrent attacks, which are sometimes
very obstinate in character,
IMPETIGO CONTAGIOSA
This disease is dependent upon a localized skin infection. It
is contagious, several children in the same family or school often
having the disease at the same time. I have known one school-
child to infect an entire class of twenty. Cases of impetigo are
seen almost daily in out-patient work. There are no constitutional
symptoms, there is rarely any itching, the only evidence of the
disease being disfigurement of the skin occasioned by the dry,
adherent crusts. The encrusted areas may be isolated or they may
coalesce, forming large masses.
Treatment. — The most satisfactory treatment with me has been
to soften the crusts with sterilized oHve oil applied on gauze,
the gauze having first been saturated with the oil. The oil-soaked
gauze is then bound to the parts. Usually in twenty-four hours
the crusts mav readilv be removed. Afterward an ointment com-
posed of ID percent boric acid in ungt. aquae rosae, or one composed
of lo percent ichthyol in vaselin, should be appHed on sterile gauze
and bound to the suppurating surface. The dressing should be
changed at least night and morning. Recovery is usually complete
in from two to three days, ^\^hen the crusts are on the lips or
other portions of the face where the dressing described cannot readily
be applied, they should be kept moist with either the boric acid or
ichthyol ointment. Fresh ointment should be applied at least every
three hours, both before and after the crusts are removed, if treated
without the use of the gauze.
PEMPHIGUS
Pemphigus in the newly born is an infection of the skin mani-
festing itself in a bullous eruption which may appear on any portion
ERYTHEMA NODOSUM 409
of the skin surface. An epidemic of pemphigus occurred a few years
ago in the New York Infant Asylum. The patients were mostly
well-nourished infants, and nearly all that were born during a
period of four weeks, twenty-six in number, developed the disease.
The blebs varied in size from one-eighth to one-half inch in diameter
and were filled with light yellow serum. The examination of the
serum showed uniformly a pure culture of the staphylococcus albus.
Treatment. — The management consisted in opening the blebs and
in the application of various antiseptic solutions and ointments.
Not much improvement followed the treatment, nothing worthy of
note being discovered until creolin baths were used. This treatment
not only relieved those cases which had developed, but the systematic
bathing in a i percent creolin solution of all the newly born in the
institution prevented the spread of the infection.
In two cases seen by me in consultation, pemphigus was associ-
ated with a marked syphilitic infection. The patients lived in the
country at a considerable distance from New York city and facilities
for taking the serum for examination were not at hand. In a general
way the infants presented the same clinical appearance, with the ex-
ception that the syphilitic cases were much more severe. There
was fever with considerable dermatitis. The blebs also were pres-
ent on the palms of the hands and soles of the feet, which was not
the case in the simple staphylococcus cases. Both the syphilitic
cases terminated fatally within twenty-four hours after my visit.
ERYTHEMA NODOSUM
Erythema nodosum is characterized by the formation in the
skin and subcutaneous connective tissue of multiple brownish
nodules of varying size. They are most frequently seen over the
anterior surface of the leg, less frequently posteriorly. They are
exceedingly painful to the touch. In two of my cases they were
associated with peliosis rheumatica, and all were in rheumatic
subjects. Pigmentation follows the disappearance of the nodules.
There is usually moderate fever and the child complains of general
soreness and pain throughout the body, in addition to the pain
caused by the nodules.
Treatment. — The patient should be kept in bed until the acute
febrile period is passed and the nodules begin to disappear. The
treatment is begun with the administration of one or two grains
of calomel followed bv a saline laxative. As the disease is probably
one of the many protean manifestations of rheumatism, it should be
treated as to diet and medication according to the suggestions laid
down in the section on Rheumatism. The most satisfactory local
measure for the relief of pain is the lead and opium solution, U. S. P.
Soft old linen or gauze is moistened with the warm solution and
applied to the parts, over which oiled silk or rubber tissue is placed
4IO DISEASES OF THE SKIN
to prevent too rapid evaporation and held in position by ban-
Illustrative Case. — A patient, at present under treatment, is
having her third crop of nodules, the different crops having appeared
at intervals of about three months. The first attack was associated
with peUosis and urticaria. The treatment which I had emploved
successfully previous to this case was that of the salicylate and
bicarbonate of soda, and antirheumatic diet. This patient, who is
markedly rheumatic, had taken large quantities of the salicylate,
and its readministration had no effect; but the nodules began
to diminish and disappeared completely in the two previous attacks
under the administration of thirty grains daily of the iodid of pot-
ash. The present attack is also subsiding under its influence.
The duration of my cases has been from ten days to three weeks,
with the exception of the one referred to, which persisted for six
weeks, or until the iodid w^as brought into use, when the improve-
ment was prompt.
ERYTHEMA MULTIFORME
As its name indicates, this disease manifests itself in many differ-
ent forms. There may be reddened papules, macules, and erythema-
tous areas, all of which are most frequently found over the dorsal
surfaces. In children there are usually associated disturbing dis-
orders of indigestion. Children of rheumatic inheritance are the most
frequent sufferers. The condition is often confused with urticaria. As
a result of the infiltration into the skin, the lesion of erythema mul-
tiforme requires several days for resolution to take place, while the
lesions in urticaria are very transient in character, rapidly appearing
and disappearing. In erythema there is usually very little itching.
The treatment consists in relieving the constipation, or whatever
digestive disorder may exist, and the use of salicylate of soda ; for a
child five years of age, from eight to twelve grains daily should be
given, in divided doses after meals. In case there is itching or irri-
tation of the parts, an ointment composed of menthol, ten grains to
one ounce of ungt. aquae rosae, will usually furnish relief. The erup-
tion seldom lasts longer than a week. A pigmented area may re-
main at the site of the lesion.
RHUS POISONING; IVY POISON
Contact with Rhus toxicodendron produces in many people a
most active dermatitis. There is marked burning with considerable
itching of the involved surface. There may be a simple erythema,
but usually there are small vesicles and bullae filled with serum, which,
if they become infected, form pustules with the possibility of mul-
tiple abscesses. When the face is involved, great disfigurement
may result.
FURUNCUMJSIS; HOILS 4II
I have used various measures from time to time in the treat-
ment of this form of dermatitis. For the acute stage — the period
of itching, burning, and edema — there is no better remedy than
the fluidextract of (irindvlia robusta — one to one and one-half
drams to the pint of water. In the very acute cases one dram
would better be used at first. It is best apphed on Hnt or soft old
linen as a wet dressing. The solution should be used cold and re-
newed every fifteen to thirty minutes. During the stage of resolution
a saturated solution of boric acid may be used in the same way, or,
what is more convenient, an ointment composed of 5 percent* boric
acid in ungt. aquae rosae. This is applied to the parts on linen,
after which resolution usually takes place promptly. When pus-
tules develop they must be opened and the parts treated with a
wet dressing of a saturated solution of boric acid.
FURUNCULOSISj BOILS
Boils are frequently seen in delicate, poorly nourished children,
and are usually due to the inoculation of the skin with the staphy-
lococcus. There is no evidence of any abnormal constitutional
state other than malnutrition. The boils occasionally develop
in well babies. Under proper management there will be a crop or
two, but perhaps not over five or six boils in all. In marasmic
cases, in hospital work, I have opened over one hundred on one
patient in caring for the successive crops as they appeared.
Treatment. — Local. — When pus is evident in the boil, a free in-
cision should be made and the pus expressed. The skin about the
wound should be washed vigorously with tincture of green soap
or ordinary soap and water. Applying a few drops of a solu-
tion of bichlorid of mercury is of little or no value. This in
itself will not be sufficient to prevent a reinfection; as some pus
invariably escapes upon the surrounding healthy skin when many
boils are opened. A wet disinfectant dressing or a disinfectant
ointment should follow incision and cleansing. Bichlorid dress-
ings are to be used only temporarily in children. The dressing
which has appeared best to prevent the spread of the infection
is a saturated solution of boric acid, which is used on gauze or
lint, when the involved area is not too large. In a marantic child,
when a considerable portion of the surface over the trunk or thorax
needs to be covered, the repeated renewal of the solution causes
a reduction in temperature which is not desirable. In such infants,
and in out-patient work where a wet dressing cannot be used, an
ointment of 15 percent boric acid in vaselin is thickly spread on
Hnt and applied to the wound and for a considerable distance about
it. The dressing should be changed every six hours. Ichthyol
is of little service when used in a strength of less than 20 percent.
The odor is disagreeable, it stains the skin and the clothing and
412 DISEASES OF THE SKIN
controls the condition no better than does the boric acid ointment.
Another advantage is that the latter is comparatively inexpensive.
With fat children, who sometimes develop boils on the abraded
surfaces at the folds of the neck or the nates, and in children who
perspire freely, I have used a dusting-powder composed as follows:
I^. Pulveris acidi borici oj
Pulveris amyli
Pulveris zinci oxidi aa oiss
M. Sig. — Dusting-powder.
This is applied as soon as the wound is closed, and the parts are
kept dry with it.
Constitutional. — The constitutional treatment is important. If
the child is marasmic or if he has malnutrition, suggestions found
under those headings should be brought into use. In the many
cases I have treated, internal medication other than that directed
toward the improvement of the general constitutional condition
has been without value. The sulphid of calcium and other drugs
which are supposed to have a direct influence upon the condition
have proved of no service. They were not considered valueless
because the patient did not recover, for if the patient is not too
reduced in vitality he always recovers, regardless of the treatment.
Observation on a series of cases of this type for which opportunity
was afforded by institution work has shown that those treated with the
sulphid of calcium, for example, made no greater progress than did
those to whom it was not given. This line of treatment is an example
of "heredity in medicine." A remedy has been advocated by some
one of consequence in the past. It is then handed down from gen-
eration to generation by writers, many of whom, not having had
opportunity to place observations of value behind their advocacy
of the measure, have simply repeated what has been said by others.
No matter how extensive the process, children with furunculosis
may be bathed as in health. The water used for the bath should
first be boiled, and in it bicarbonate of soda, one tablespoonful
to the gallon, should be used. Of course, there should be little or
no friction of the skin.
SCABIES; ITCH
Scabies is a contagious disease of the skin caused by the bur-
rowing of the acarus scabiei. The disease is seen with considerable
frequency among out-patient children. The cases differ greatly
in severitv, but, in all, the treatment is practically the same, vary-
ing only as to the necessity of repeating or continuing it. At bed-
time a hot bath is ordered, from 105° F. to 110° F. While in the
bath the patient is vigorously scrubbed with a towel, using the
yellow laundry soap. After the scrubbing he is dried vigorously
and sulphur ointment, U. S. P., is rubbed as vigorously into the
skin. In forty-eight hours the process is repeated and again repeated
forty-eight hours later. A repetition at twenty-four-hour intervals
bed-sores; decubitus, pediculi
413
is usually too irritating to the skin. The third treatment usually
terminates the case. In quite young children, in whom the sulphur
ointment may be too irritating, it may be diluted one-fourth or one-
half by the addition of vaselin. This may be done with older chil-
dren also if the first application produces considerable dermatitis.
Care must be exercised in destroying, boiling, or disinfecting all
clothing previously worn by the patient.
BED-SORES? DECUBITUS
During any illness with greatly disturbed nutrition, as in cerebro-
spinal meningitis, typhoid fever, empyema, or in any prolonged
illness with emaciation, constant pressure on the prominent bony
parts inteferes sufficiently with the circulation to cause destruction
of the integument. The
most frequent sites for ^
decubitus in children are /' -«_
the sacrum, the heels, and
the back of the head.
The condition is best
prevented by cleanliness,
both as to the patient and
the bed linen, and by
keeping the latter smooth
and frequently changing
the position of the patient.
The parts as they become
sensitive and show redness
should be bathed several
times a day with alcohol.
If this does not relieve the
condition, the areas should
be covered with diachylon
plaster so as completely
to cover and protect the involved areas. The air-cushion or the
water-bed may be necessary in any prolonged illness.
When the back of the head is involved, the scalp should be
shaved and the head allowed to lie in a home-made head-rest
which is constructed as follows (Fig. 43): A piece of fairly stiff
wrapping-paper, four inches wide, is twisted into a rope, of which
a circle four to five inches in diameter is made by bringing the ends
together. The paper is then wrapped thickly with absorbent cotton,
which is in turn wrapped with a two-inch roller bandage.
Fig. 43.— Head-rest to Prevent Bed-sores.
PEDICULI
Head lice, or pediculi capitis, are very frequently seen in out-
patient and hospital work among children in all the larger cities.
414 DISEASES OF THE SKIN
Occasionally children become infected in school or in public convey-
ances, and carry the vermin to other members of the family.
The most successful and cleanly treatment consists in cutting the
hair short; this done, wash the head with soap and water twice a
day, and after drying moisten the scalp thoroughly with the following
solution, daily:
I^. Acidi acetici 5ij
.4itheris sulphurici 5 iij
Tincturae delphinii
Spirit! vini rectificati aa 5iv
Improvement will follow a few treatments. The pediculi will be
killed and the nits may be removed with a line-tooth comb. If the
patient is a girl, it is not absolutely necessary to sacrifice the hair.
It may be parted from various portions of the scalp and the solution
appHed without previous washing. However, if the hair is not cut, a
much longer time will be required to effect a cure.
TINEA TONSURANS; RING-WORM OF THE SCALP
Ring-worm of the scalp due to the action of the trichophyton
tonsurans is of frequent occurrence, and on account of its conta-
gious nature is a disease greatly dreaded in institutions for children.
An epidemic once started is only with the greatest difficulty eradi-
cated. The appearance of the scalp is characteristic. Beginning
with a few small vesicles, the process extends from the periphery
outward, showing the scaly desquamating scalp, and the short stubby
hairs broken at their points of exit from the scalp. There may be
but one area involved or there may be a dozen. I have seen almost
complete baldness result from the coalescence of many of these
areas.
Treatment. — Cures are difficult and the treatment must be along
radical lines. In an epidemic several years ago at the Country Branch
of the New York Infant Asylum, abundant opportunity was offered
to test various measures of treatment that had been advocated by
different observers. Among others were chrysarobin in various
combinations, carbolic acid, iodin, bichlorid of mercury, sulphur,
and white precipitate. As a result of much experimentation, a
useful scheme of management was established, the report of which
may be found in "The New York Medical Journal," of October 10,
1891.
The location of the fungus in the hair-follicle makes it very diffi-
cult to apply any drug so that it will be effective as a parasiticide.
In order to accompHsh this, it is absolutely necessary to cut the hair
of the entire scalp as short as possible. Upon beginning the treat-
ment the scalp is thoroughly scrubbed with soap and water, using
the strongly alkaline yellow laundry soap so as to remove all the
dead hair and desquamated epithelium. The parasiticide to be
TINEA tonsurans; RING-WORM OF THE SCALP 415
used is then rubbed into the diseased area and for a considerable
distance on the surrounding heahhy scalp. The parasiticide which
answered best with us was composed of bichlorid of mercury two
grains in one-half ounce of equal parts of olive oil and kerosene.
The bichlorid must be dissolved in a small quantity of alcohol before
it is added to the oil mixture. This is rubbed into the diseased area
every day until the scalp becomes sore and tender. In order to
prevent the spread of the infection to other parts, the solution may
be apphed every fourth day, without friction, to the entire scalp. It
is necessary in order to effect a prompt cure to produce a dermatitis
at the site of the lesion. When this occurs the treatment is tempo-
rarily discontinued. When the inflammation subsides another is
produced in like manner. After three or four weeks of this treatment
it may be discontinued and the parts kept under observation in
order to note the results. A daily application of sterile oil aids in
bringing the skin to a normal condition.
In one-third of the children in the epidemic referred to, two grains
of the bichlorid of mercury were added to one ounce of the tincture
of iodin. Twenty-six cases were treated by this method with an
average duration of treatment of eight and one-half weeks. Several
recovered in four weeks, while in others twelve weeks of treatment
were necessary before it could be discontinued. While the treatment
is under way the child should wear a cap, day and night. This may
be made of any cheap, light-weight material, which after a day or
two of use may be burned. Cheese-cloth caps were used in our
cases. Rubber gloves were necessary to protect the hands of the
nurse who made the applications, especially if there were many heads
to be treated.
The epidemic, which included at least one hundred cases, was
controlled by the above means and prophylaxis resulted from the
use of the kerosene and olive oil without the bichlorid. It was
found impossible to maintain a quarantine permanently or effectu-
ally even for a short time, particularly during the warmer months,
therefore every inmate of the asylum of the "runabout" age who
did not have the disease was treated as though he was expected to
get it. Every head was "cUpped" and the hair kept short. Twice
a week they were given a kerosene and olive oil shampoo.
In private work the continued use of kerosene and olive oil is not
popular for reasons readily understood. In such cases the hair is
clipped as soon as the case is diagnosed and a kerosene shampoo
given. The bichlorid of mercury, two grains to one ounce of tincture
of iodin, U. S. P., is applied to the parts with sufficient vigor to
produce a dermatitis. If the disease shows a tendency to spread on
the scalp beyond the original site it is best prevented by the use of
the kerosene and olive oil, as above suggested.
4l6 DISEASES OF THE SKIN
TINEA CIRCINATA
Ring- worm is produced by the vegetable parasite, trichophyton.
It may develop upon any portion of the skin surface. The treat-
ment is the use of some irritant that will produce a desquamation
of the epidermis in the superficial layers of which the parasite is
located. The tincture of iodin has proved a satisfactory remedy if
the disease is located where its use is possible. Two or three
applications of the U. S. P. tincture is all the treatment that is
ordinarily required. If the case is at all obstinate, two grains of
bichlorid of mercury may be added to the ounce of the tincture of
iodin. If the lesion is situated on an exposed surface such as the
face, five grains of bichlorid of mercury may be dissolved in equal
parts of alcohol and glycerin and applied locally.
MILIARIA; PRICKLY HEAT
In prickly heat there is an acute engorgement of the vessels of
the sweat-glands with obstruction of their outlets. Minute papules
form which are reddish in color. The mild cases are without inflam-
mation. When inflammation develops, small vesicles also appear,
and may cover large areas of the body. Nearly every infant suffers
from prickly heat in the summer. It is most frequently seen on the
head and neck and over the chest and shoulders. The patients are
very uncomfortable and restless. There is evidently a great deal
of burning and itching. The condition is caused by heat, due either
to too much clothing or to the hot weather of summer; both causes
may be operative. I have frequently seen it in winter in overclad
children. Most babies are overclad at all seasons of the year. When
prickly heat develops, regardless of the season, it is a sure sign that
the child has been kept too warm. The duration of the miliaria is
dependent upon climatic conditions and also upon the treatment. I
have seen cases which existed for months.
Treatment. — Heavy clothing and flannels are to be avoided. In
order to lessen the local irritation, the garment worn next to the skin
may be lined with silk, linen, or gauze. The further means of manage-
ment as regards both the relief afforded the patient and the cure of
the condition, consists in the frequent application of cool water, in
the form either of a tub-bath or sponging. The soda bath, the bran
bath, and the starch bath (pp. 30, 31) are all most useful. For pur-
poses of sponging, a solution of bicarbonate of soda should be used
— one tablespoonful to a gallon of water. The relief afforded the
patient depends not so much upon what is used in the water as upon
the fact that plenty of cool water comes in contact with the itching,
burning skin. Ointments and salves are of little service here, as
they tend to produce further maceration of the skin. As local appli-
miliaria; prickly heat 417
cations, powders are preferred to lotions. A powder used with satis-
faction in this condition is of the following composition:
I^. Acidi salicylatis gr. x
Acidi borici gr. Ix
Pulveris amyli
Pulveris zinci oxidi aa oj
This is to be dusted freely over the involved surface several
times daily, every hour if necessary. In case irritation is produced
by the saHcylic acid it may be omitted or its strength may be de-
creased by the addition of powdered starch.
27
DISEASES OF THE EAR
EARACHE
In every case of earache in an infant or young child the ear-drum
should be examined. It' may show intense congestion and bulging,
requiring immediate incision, or there may be but slight congestion
about the periphery of the drum and at the tip of the malleus.
When the latter condition exists there are various means of relieving
the pain, the most effectual appHcation of drugs being probably
instillation into the ear of equal parts of a 4 percent solution of cocain
and camphor-water; five drops of the warm solution are dropped
into the ear and repeated every half hour if necessary; after which
dry heat may be appHed by the use of a hot-water bottle or a salt
bag. I have frequently relieved severe attacks of earache by means
of a hot-water douche — one pint of water at 110° F., using a douche-
bag or a fountain syringe. When the pain is not promptly relieved
the ear should be carefully watched, particularly if there are recur-
rent shooting pains, a throbbing sensation, or a feeling of fullness
in the ear. In young children a rise in temperature associated
with earache is often indicative of an acute infectious process in
the middle ear, and, in addition to the treatment suggested, the ear
should frequently be examined, in order to be prepared for early
incision of the drum membrane should it be required.
ACUTE OTITIS
Acute otitis rarely occurs in infants and children as an inde-
pendent affection, but is usually a complication of, or a sequela
of some infectious disease. Among my own patients a great majority
of cases occurred in association with or following an acute inflam-
matory condition of the upper respiratory tract due to a mixed
infection — a condition which occurs in many of the illnesses of
infancy and early childhood; thus, it not infrequently follows
simple rhinitis, pharyngitis, tonsillitis, grippe, measles, or scarlet
fever. The disease is of much more frequent occurrence in children
than in adults. The younger the child, the greater the apparent
susceptibility. This susceptibility in the young is due chiefly to
three causes: the comparatively patent eustachian tube, the ten-
dency to inflammatory conditions of the throat, and the presence
of adenoid growths in the pharyngeal vault — features favorable
to the development of infection and for its extension to the cavity
of the middle ear.
418
acute; otitis 419
Otitis in young children is probably more frequently overlooked
by the practitioner than is any other disease of childhood. This
is through no fault of his own; it is because of its indefinite mani-
festations, and the faulty teachings of text-books as to the symp-
tomatology of the disease. In a search of many works on otology,
I find that the symptoms as laid down are dependent almost ex-
clusively upon evidences of pain — earache — the pain being com-
plained of by older children or manifested in the very young by
vigorous crying, by tossing the head from side to side, by head-
rolling, ear-tugging, crying out in sleep, disinclination to rest the
head on the affected side, pain upon manipulation of the ear — in
short, we have been taught that there is invariably some manifesta-
tion of pain referable to the ear or the adjacent structures in all
cases of acute otitis in infants and young children.
Illustrative Cases. — What symptom is most frequently associated
with otitis in children? In seventy-two private cases one symptom,
and only one, was present in all — fever. The otitis was apparently
primary in three. In these the condition did not follow and was not
associated with any previous abnormal state, as far as we were able
to judge. One was associated with or followed German measles ; two,
scarlet fever; seven, measles; and fifty-eight, grippe or catarrhal
colds. In the cases in which the otitis followed, but was not immedi-
ately associated with any of the preceding diseases, which was the rule
in the majority of the cases, there was nothing especially character-
istic in the temperature range. In some there were the morning
drop and the evening rise ; in the others tTiere was no regularity as
regards the temperature range. With but few exceptions the
otitis developed during convalescence from an acute process else-
where, the ear involvement being suspected because of a persistent
elevation of the temperature for which no other cause could be
discovered. The fact that fifty-eight of the cases, or 81.5 percent,
occurred with or followed non-specific, inflammatory conditions of
the upper respiratory tract, such as tonsillitis, grippe, and catarrhal
colds, emphasizes the necessity for frequent aural examinations
during or following such disorders, particularly when there is an
elevation of the temperature — a temperature which, in the absence
of definite clinical signs, we are apt possibly to attribute to chronic
grippe, malaria, typhoid fever, or dentition.
The most interesting factor in this series of cases was the absence
of pain or localized tenderness on manipulation in fifty of the cases,
or 69 percent. Among those included in the pain group, twenty-
two in number, there are some which perhaps should not be so
included. In these there were no signs of pain, as we generally
expect to find it; but in this group are included those who were
very restless, who slept poorly, and those who showed evidence of
any great discomfort. Upon discovering the ear disease and noting
420
DISEASES OF THE EAR
the relief which followed incision of the drum membrane, it was
fair to assume that the source of the previous discomfort was the
ear. Had we depended for the usual signs of pain or local tenderness,
in fifty of the cases a diagnosis of otitis at the time would have been
impossible. Six were seen in consultation, because of the unex-
plained, continued fever. Nine had been treated by other physicians
who had failed to discover the cause of the continued fever. In
Fig. 44.— Hard-rubber Ear Syringe.
none of these had ear involvement been suspected, because of the
absence of pain and localized signs.
Treatment. — Operative. — Every practitioner who has children for
his patients should be sufficiently familiar with the landmarks of the
normal drum membrane at the various ages of early life to differen-
tiate the normal from the abnormal. In the routine examination of
the child, the ear should be included in all
conditions associated with angina or fever.
In quite young babies an otoscopic examina-
tion may show a dull whitish-appearing drum
membrane which on a superficial examination
of the case might be ignored. In all cases,
particularly at this age, when the drum land-
marks are indistinct, a cotton-pointed probe
should be brushed over the surface, thus re-
moving the epithelial scales which may have
lodged there, when perhaps a congested, bulg-
ing membrane may be revealed. This point
was brought out by Dr. J. F. McKernon
in January, 1899, in a discussion before the
State Medical Society at Albany.
Conditions or appearances of the drum
membrane which require incision are often
difficult of recognition by those not skilled in
otoscopy. When the drum is bulging, deeply
congested in appearance, with landmarks indistinct, an incision is
necessary, and should be made in the posterior quadrant, beginning
low down and extending upward through Shrapnell's membrane.
When also there is congestion of the drum membrane over the tubal
entrance, w^hen the congestion extends toward the periphery with
indistinct landmarks without bulging, incision is indicated.
Post-operative. — The after-treatment following incision consists in
ACUTE OTITIS 421
syringing the ear at three-hour intervals with eight ounces of a
I : 10,000 solution of bichlorid of mercury for three or four days, when
the syringing may usually be practised at intervals of from four to
five hours until the drum closes. In very young infants if the bi-
chlorid causes a dermatitis at the meatus, it is well to change to a
sterile normal salt solution, using the same quantity of fluid. In
those cases in which only serum is present at the time of operation,
a closure in ten days may be expected ; if, however, pus is present,
from two to three weeks will be required. A sudden stopping of
the discharge usually means that the opening in the drum is closed,
^^
A?5*''/
Fig. 46.— Syringing the Ear.
either through plugging of the opening with thick pus or because
of the too early heaUng of the drum: in either event a reestablish-
ment of the discharge is required by removing the obstruction or
by reincision. The chief factors in prolonging the discharge are
adenoids and a lowered state of physical resistance. After syring-
ing, the ear should be carefully dried with absorbent cotton. For
purposes of syringing, a one-ounce hard-rubber ear syringe with
soft-rubber tip (Fig. 44) answers best. If this is not obtainable a
douche-bag, at an elevation of not more than three feet above the
patient's head, may be used. The douche-bag sometimes answers
better for those who are unskilled, or a soft-rubber bulb syringe of a
capacity of one to two ounces may be used (Fig. 45). With either
422 DISEASES OF THE EAR
method, the child rests on his back with his hands pinned to his
side by means of a large bath towel, with a pus basin under the ear
to catch the flow (Fig. 46). If the nurse can have an assistant the
upright position may be used.
DEAFNESS
Hearing is probably established in the newly born during the
first two or three days of life. During the early months of life
the hearing is very acute. Acquired deafness is not at all unusual,
however, even in comparatively young children. Among its most
frequent causes is an extension of an inflammation from the throat
to the tubal mucous membrane. In diphtheria, in the exanthe-
mata, in grippe, in tonsillitis, and in many other ailments of early
life, there is an associated inflammation of the nasopharyngeal
structures. Unless infection of the middle ear occurs, deafness
is usually of a very temporary nature. Persistent deafness may
be the result of enlarged tonsils, adenoids, or organized changes
in the canal or in the middle ear. Among the most frequent causes
of persistent deafness in children are adenoids and scarlet fever.
Deafness at rare intervals follows an attack of mumps and is due
to an involvement of the labyrinth, and calls for expert otologic
treatment.
Deaf children whose condition is not recognized are often accused
of inattention and punished when they are slow in responding when
spoken to. They make slow progress in school and are considered
stupid. Many such children show defective hearing of a pronounced
type, due usually to enlarged tonsils and adenoids.
The management in these cases is to remove the adenoids and
tonsils. When relief is not afforded by operation, the child should
be taken to an aurist for a careful examination as to the condition
of the ears and the hearing capacity.
CHRONIC SUPPURATIVE OTITIS
Not infrequently cases come under our care in which there is a
purulent discharge from the ears, oftentimes most offensive, with
a history that the discharge followed measles, scarlet fever, or grippe,
and that it has continued for weeks or months. Examination may
show a perforation of the upper portion of the drum, through which
there is a free discharge, but on account of the site of the perfora-
tion not sulflcient to drain completely the middle-ear cavity; or
there may be only a small perforation, too low for effective drainage.
In either case incision should be made and free drainage established.
The ear should then be syringed (Fig. 46) at least three times a day
with a I : 10,000 bichlorid solution. In cases of chronic suppurative
otitis it is well to examine for adenoids, as these growths in the
nasopharyngeal vault will help to keep up the discharge indefinitely.
MASTOIDITIS 423
The presence of dead bone and granulations is also to be considered
in the chronic suppurative cases, and the examination is not com-
plete until the condition of the nasopharyngeal vault is determined.
When the presence of dead bone or granulations is established, it
calls for radical operative procedures by a skilled otologist in order
to avoid mastoid and intracranial complications.
MASTOIDITIS
It is not necessary to wait for swelling in the post-auricular
region, or pain or tenderness over the mastoid in order to make
a diagnosis of mastoid disease. The child may object quite as
strongly to pressure on the unaffected side or to pressure elsewhere
on the skull, which completely negatives what one might hope to
elicit by tenderness. Involvement of the mastoid cells may be
looked for in any case in which there is pus in the middle ear. A
daily elevation of the temperature in purulent otitis with a freely
discharging ear is very suggestive of mastoiditis, particularly if
there is no other readily assignable cause for the fever. The further
signs, continued fever with prolapse of the posterior superior wall
of the canal, with the canal rapidly filling with pus after syringing,
mean that mastoiditis is almost sure to be present and operation
is indicated. With tumefaction and swelHng of the soft parts be-
hind the ear — the so-called perimastoiditis — the mastoid cells and
antrum will almost invariably be found involved and the radical
mastoid operation should be performed.
GLANDULAR DISEASES
ACUTE ADENITIS
The management of acute adenitis in a child depends to a cer-
tain extent upon the age of the child and the factors producing
the adenitis. One thing is to be remembered, however, in the
treatment. It is this: The constant application of an ice-bag will
do more toward controlling the adenitis and preventing complica-
tions than will any other measure which we possess. Unfortunately,
in infants and in a few young children, it is not practicable, being
particularly difficult when, as is generally the case, the cervical
glands are involved, since it is then almost impossible to keep the
ice-bag in place. In older children, after the second year, it should
be applied continuously day and night. Where ice cannot be used,
I apply the cataplasma kaoHni as follows: A piece of linen, suffi-
ciently large to cover the swollen area, is thickly covered with the
paste and applied to the parts. A fresh application should be
made every six hours, or the following ointment may be used:
I^. Ichthyoli oiiss
Unguenti zinci oxidi q. s. ad oj
The ointment is applied freely on linen, which is covered with
oiled silk and held in position by a suitable bandage. Many mothers
find it more convenient to use a cap made of cheese-cloth, which
covers the dressing and holds it in place. The ichthyol ointment
should be freshly applied every six hours. In cases where other
measures have been unsatisfactory, I have used successfully Crede's
ointment, fifteen grains of which are rubbed into the swollen areas
twice daily.
Not only is it necessary to treat adenitis locally, but the source
of the infection must be sought for and if possible eradicated. In
cervical adenitis the source of the infection is in the mouth or in
the throat. Decayed teeth, enlarged tonsils, and adenoids will prob-
ably require attention. So also acute tonsilHtis and diphtheria, the
anginas of grippe and the exanthemata, are conditions any one of
which may cause cervical adenitis, which is usually due to a mixed
infection. The majority of my cases which have gone on to suppura-
tion have been either a pure streptococcus infection or the strepto-
coccus was the most prominent. Such infections may take place
with any of the acute infectious diseases, but they are most frequently
met with in scarlet fever. In inguinal adenitis, balanitis in boys or
vulvovaginitis in girls is usually the source of the infection.
424
PERSISTENT ADENITIS 425
Even when the ice-bag is appUed with the first suggestion of
swelHng and used faithfully, the cases of streptococcus infection
sometimes go on to suppuration. Repeatedly I have seen the aden-
itis, which is often an early compHcation of diphtheria, disappear
quickly after full doses of diphtheria antitoxin. Acute adenitis ter-
minates in one of three ways — resolution, suppuration, or persistent
adenitis. When the swelling softens, we know that suppuration has
taken place, and our only treatment is to incise freely, allowing the
pus to escape, and place in the wound a strip of sterilized gauze
to assist in drainage and to prevent too early a closure of the incision.
The wound should be dressed once daily. Extirpation of the dis-
eased gland is not to be advised until later, if at all.
PERSISTENT ADENITIS
After an acute adenitis, in a small percentage of cases, the gland
or glands will remain persistently enlarged, so as to constitute a defor-
mity, or the deformity may be the result of a series of acute attacks,
each leaving the gland a Httle larger than before. Whether these
glands are tuberculous from the outset or become so later, it is im-
possible to state. I know, however, from an observation of several
cases, that many of those which do not show the distinctive character-
istics of tuberculous adenitis which we have been taught to expect, do
show that they are tuberculous upon examination after operation —
the glands having been removed because of the unsightly deformity;
I have, therefore, come to look upon pronounced persistent adenitis
as probably of tuberculous origin, even though but two or three
glands appear to be involved. Because these chronically enlarged
glands sometimes undergo resolution without suppuration does not
prove the absence of tubercle bacilH.
Treatment. — I have treated these cases of persistent adenitis with
electricity, massage, drugs, and local applications, but am unable to
advise the use of any one of them, nor have the iodids in my hands
been of any appreciable value. Constitutional means, of course,
should be employed — iron, cod-liver oil, and the hypophosphites
being prescribed if the child's condition appears to require them. In
many cases, however, such treatment is not called for, as the chil-
dren are in perfect condition, the process being entirely a local one.
I have had no experience with the "x-ray" and various "light"
methods of treatment which are advocated by some writers. My
own observation in the management of these cases has been that
when the glands remain for several weeks sufficiently large to pro-
duce a deformity, removal by surgical means is the onlv course to
pursue. The operation is a simple one, is quickly performed, and
need leave but a very slight scar.
426 GLANDULAR DISEASES
ADENOIDS
By the term "adenoids" is understood a hypertrophy of the
mucous glands of the nasopharyngeal vault. They may be associated
with an enlargement of the tonsils, or be entirely independent of it.
The growths vary in consistency from friable, sponge-like tissue
filled with blood, to those composed largel}^ of firm connective
tissue. The age of the child appears to exert but little influ-
ence upon the character of the growth. I have removed hard,
firmly organized growths from children of eighteen months and two
years, and soft, sponge-like masses from children seven or eight
years of age. The amount of growth varies also, from a slight
fringe of hypertrophied glands situated high up on the posterior
pharyngeal wall, to a large mass which completely fills the naso-
pharyngeal vault.
Adenoids may occur at any age, but are more common in children
from two to six years of age. The youngest case I have operated on
was six months of age. Cases of congenital adenoids have been re-
ported. Some children have large, roomy, nasopharyngeal vaults;
while in others, on account of the high palatal arch and the promi-
nence of the bodies of the cervical vertebrae, the space is very small.
In such cases a very small amount of adenoid tissue causes marked
obstruction.
The symptoms vary according to the character and the amount
of the growth. With a small growth in a roomy vault, there is apt
to be a history of a nasal discharge which is usually regarded as a
chronic " cold." Many of these cases with a small amount of actively
secreting adenoid tissue have most persistent coughs (page 255) , which
are worse w^hen the child lies down. There may be nothing more than
a clearing of the throat ; usually, however, the cough is more or less
persistent. Now and then it is paroxysmal, and so closely resembles
whooping-cough that an error in diagnosis is often made. Such
cases oftentimes pass unrecognized. The presence of adenoids is
not suspected because breathing is unobstructed, the cough being
attributed to the stomach, to dentition, to nervousness, etc. When
there is a decided obstruction to breathing, whether due to a large
growth or to a small palatal vault, the characteristic signs are sure
to be present: The open mouth, the snoring at night, the stupid
expression, the disturbed articulation, the persistent nasal dis-
charge, the deafness, the inability to blow the nose, the cough,
and the story of chronicity, — all combine to make a picture which
can be produced by no other condition. No special class or type
of child is affected. We find adenoids not only in the delicate and
ailing, but also in the strong and well. Out of hundreds of cases,
I have seen very few in which lymphatism could be accused of
having any part in the production of the growths.
ADENOIDS 427
When to Operate. — The management is operative in every case
in which the growth produces symptoms which compromise the heakh
and comfort of the patient. Early infancy is no contraindication to
operation, if the conditions are sufficiently urgent, h'ortunately, the
necessity for a radical operation in the very young, that is, in those
under one year of age, is extremely rare. These httle patients, how-
ever, may have growths sufficient to cause an obstruction, which
gives rise to mouth-breathing, to difficulty in nursing, and to a very
annoying and persistent nasal discharge.
Operation for Temporary Relief. — In several instances I have
relieved these cases temporarily by crushing the growths with the
clean index-finger. At this age the adenoid tissue is usually very soft
and friable. The finger-nail should be cut very short and the whole
hand thoroughly scrubbed and disinfected. The child is wrapped
and pinned, usually in a large towel, so that the arms are confined
to its sides, and is then placed on its back on the bed or table. A
clean towel for wiping away the blood should be placed under the
head. The mother and nurse should be advised that a slight bleed-
ing is expected. With the child thus in position, the physician
holds the mouth open with a spoon or tongue depressor, and passes
the clean index-finger of the right hand backward into the vault
and easily breaks up the soft, spongy growth which may be present.
The adenoids are by no means removed by this method, but their
continuity is destroyed and portions of the growth doubtless slough
off", thus affording temporary relief. The child will be able to nurse
without inconvenience and the nasal discharge will stop. Opera-
tion, however, is thus only deferred until the patient is older. In six
months or a year the symptoms will return.
Operation for Permanent Relief. — The only permanent relief lies
in a curettage of the vault, and even with a complete removal of the
growth by curettage and forceps, there may be a return if the opera-
tion is performed on the very young — those under two years of
age. When asked by parents if there is danger of a return of
the growth, I always reply that a return is possible, and always
takes place in a small percentage of the cases. The older the child
at the time of the operation, the less the liability of a recurrence.
The possibility or probability of a return is no argument against
the removal of the growths in the very young, for by the time the
child is three or four years of age, a great deal of permanent harm
may have resulted.
As operation is the only method of treatment, it is one with
which the general practitioner should by all means familiarize him-
self. The operation is not performed by all ahke. Some prefer
the sitting position without an anesthetic ; others employ anesthesia
and raise the patient to a sitting position at the time of the opera-
tion. It is my opinion that an anesthetic should be used in every
428
GLANDULAR DISEASES
case, unless contraindicated by some such condition as lymphatism or
cardiac or kidney disease, which might make the anesthesia danger-
ous. Regarding the choice of an anesthetic, my preference is to give
nitrous oxid gas in children over two years of age to produce uncon-
sciousness, and then substitute ether. This method is far more
agreeable to the patient than when ether is used from the beginning.
Primary anesthesia is all that is required. In the very young,
when gas is not permissible on account of producing cyanosis,
ether alone may be used. Chloroform I have learned to regard
with much distrust. A boy three years of age upon whom I was
to operate for adenoids came near dying under chloroform anes-
thesia ; resuscitation was almost despaired of. With another child I
had a similar experience. I have never experienced any unpleasant
effects from ether during these operations.
Fig. 47.— Position for Adenectomy and Tonsillotomy.
If the operation is to be performed without an anesthetic the
upright position is the best. The child's arms are bound to its
sides with a large tow^l and fastened with safety-pins. He should
be held on the lap on the right side of an attendant, who by cross-
ing his legs confines the legs of the patient between his own. The
attendant's right arm encircles the child while the left controls
the head, which rests against his right shoulder. A basin should
be within reach of the attendant, as the bleeding is sudden and
profuse.
If an anesthetic is used the child is placed on the table (Fig. 47)
with the arms bound to its sides by a large towel or sheet. The
Denhardt gag of the O'Dwyer intubation set is used to keep the
jaws open. The growth should be located with the finger, and any
RETROPHARYNGEAL ADENITIS 429
adhesions which may be present should be broken up. If the tonsils
are to be removed, that should first be done. As soon as the adenoids
are removed, the patient is turned on his side so that the blood can
drain into a basin which should be in readiness on a chair at the
side of the operating table. Before removing the gag the operator
should pass his finger into the vault to determine if it is clear; if
not, the curet must again be brought into use. The Knight or
McAuliffe forceps may be utilized in removing any shreds of tissue
which may have been left behind. Two curets are usually necessary,
a small and a larger one (Figs. 48 and 49). The operation can be
more successfully performed if a curet is used in which the blade
stands at an angle, as represented by the drawings. This allows a
greater play of the cutting-blade in the vault. A moderate amount
of blood is swallowed, which is usually vomited in the course of an
hour or so. Parents should be told that this may occur. The child
should be kept in bed for the remainder of the day on a reduced
C
Figs. 48 and 49. — Adenoid Curets.
diet of diluted milk, broths, and gruel. It is my custom to allow,
four hours after the operation, three ounces of milk diluted with
three ounces of water. A swallow of cold water or pieces of cracked
ice can be given at any time. Following the operation I order
for the nose an albolene spray, to be used three times daily for three
weeks.
Three months after the operation the mother is asked to return
with the child for examination. In several instances I have found
that fresh adhesions had formed between the cut surfaces and the
soft palate, which had caused a return of some of the original
symptoms. These adhesions are readily broken up with the
finger, as are also any recurring growths which occasionally may be
found.
RETROPHARYNGEAL ADENITIS
Retropharyngeal adenitis, as the name implies, is an inflamma-
tion of one or more of the glands which are situated posterior to the
pharynx between the pharyngeal and prevertebral muscles. Pain
430 GLANDULAR DISEASES
and difficulty in swallowing are always present. Other symptoms
are fever, — ioo° to 103° F., — and loss of appetite. The glands, as a
rule, suppurate, forming a retropharyngeal abscess (see page 242).
In an acute case an inspection of the throat will usually show a
swelling at the right of the median line. If situated low down on
the posterior pharyngeal wall, it may escape detection. Upon digital
examination, instead of a smooth, flat surface, the finger encounters
an elevated, rounded mass, which should not be mistaken for an
unduly prominent cervical vertebra.
In retropharyngeal adenitis, while suppuration is the rule, it
does not invariably follow. In one case, in a baby six months old,
we waited for several days for the suppuration of the gland, which
was greatly enlarged. This it failed to do, and the child recovered.
In these cases treatment must be both local and constitutional.
Local treatment consists in cleanliness. The mouth should be
washed with a saturated solution of boric acid after each feeding.
The use of iodids in adenitis in children I have found of questionable
service. More is accomplished by a suitable diet and plenty of
fresh air.
TUBERCULOUS ADENITIS
The onlv management of tuberculous adenitis which should
be entertained is surgical — the removal of the diseased glands.
After the operation the child should, if possible, be given the advan-
tage of an outdoor life in the country, inland. These cases appear
to improve most rapidly at an elevation of eight hundred feet or
more. The diet should consist of meat, eggs, milk, and of high-
proteid cereals, such as oatmeal and the dried legumes, given in
the form of purees. It is my custom to order cod-liver oil and malt
to be given in doses of from one teaspoonful to one tablespoonful
after meals for one week, followed for one week by the syrup of the
hypophosphites, when the oil and malt may be resumed for the same
time, thus alternating indefinitely with the hypophosphites. If
an examination of the blood shows that the patient is anemic,
iron may be used in connection with the other remedies. The
citrate of iron and the extractum ferri pomatum are well borne
by the stomach and have appeared to be of considerable service
in some of my cases. For children from five to ten years of age,
one grain of the citrate of iron and quinin, or one grain of citrate
of iron and ammonia, may be given after meals. The dose of
extractum ferri pomatum at this age is one-half grain after each
meal.
HEREDITY AND ENVIRONMENT
Many of the diseases, crimes, and failures of life are attributed
to heredity, as are also vigor of body, attainments, and successes.
Heredity and environment are two important determining factors
in the Ufe of the child. Both exert their influence over the individual.
I had been taught or in some way conceived the idea that the
influence of heredity was predominant, but with the closest asso-
ciation with developing children, coming into intimate relations
with hundreds of them and watching carefully their physical and
mental development, the great influence exerted by environment,
which often means only opportunity, has been forced upon me,
relegating heredity to the background. That certain diseases, such
as syphilis and hemophilia, may be transmitted from parent to
child is undisputed ; that certain physical states — the so-called con-
stitutional vices — may also be transmitted, is indisputable; but
that much of natural physical weakness and hereditary tenden-
cies may be overcome by the beneficial influence of environment
is now universally acknowledged. Heredity without favorable en-
vironment counts for little. Given an ideal heredity for a child or
one of the lower animals, place him under unfavorable conditions
of environment and his favorable heritage counts for little. Feed-
ing, care, and general good management shape his physical future
much more than does inheritance. In proof of supposed inherited
mental traits, the offspring of criminals or drunkards are pointed out
as showing how they follow in the footsteps of their fathers and
mothers. It must be admitted that here the hereditary influence
is bad, but one should remember that their environment has also
been very unfavorable.
Mental traits much more than physical are apt to have an in-
fluence on the future, and here again brilliant fathers rarely transmit
their higher mental powers to their offspring, as is proved again
and again in the professional and business world. Many of the ills
laid at the door of heredity are due to errors in early management.
In the breeding of animals great stress is laid upon pedigree, and
credit is given accordingly. It should be remembered, however,
that the stock-raiser appreciates the value of the young of his herds,
and they invariably get the care that is best calculated to develop
the perfect animal, which is exactly what the majority of the children
of the human family do not get. A well-bred animal treated as
badly from its birth to maturity would cut a sorry figure in the
animal world.
431
432 HEREDITY AND ENVIRONMENT
HABITS
Children readily acquire habits, good or bad. Under the man-
agement of an intelligent attendant, directed by the physician,
this natural tendency toward the repetition of an act may be turned
to the child's inestimable advantage. There should be established
in earliest infancy the habit of taking the nourishment at definite
periods, and as the child increases in age, proper habits of sleep
and rest must also be acquired. The child, too, should be bathed
at a stated time and aired at a stated time each day, and, in general,
in order to fulfil the requirements of vigorous animal life, his life
should conform to a routine in which there is but Uttle variation.
Our sole object being the production of a good adult, only those
habits tending toward proper growth and development should be
encouraged. The habit of self-entertainment is an important one.
An infant who requires to be constantly in arms when awake means
a tired attendant, and usually a tired and irritable child.
Bad Habits and Their Correction. — Among the bad habits early
acquired and difficult to break, is that of thumb-sucking or finger-
sucking and the use of the "pacifier." The penalty paid by these
children for such indulgence is thickened, boggy lips due to hyper-
trophy of the orbicularis oris muscle and adjacent structures. Per-
sistent sucking also produces a forward projection of the upper
incisor teeth and an angular deformity of the upper jaw. The cor-
rection of the rubber-nipple and pacifier habit is readily accom-
plished by the immediate withdrawal of these articles. The child
will experience several fretful days and make it unpleasant for those
about him. The thumb-sucking habit may be corrected by having
the child wear a mitten or glove made of muslin or old Hnen which
is shirred and tied at the wrists. Applying bitter drugs to the fingers
or thumb is usually effective in controlling the habit. The tincture
of aloes or a solution of the bisulphate of quinin, one dram to two
ounces of water, is generally used, the finger being repeatedly moist-
ened with the solution. Mothers wdll sometimes tell us with con-
siderable amusement that the application of the bitter drug to the
finger makes no difference to the child, who appears to like the taste
of quinin or aloes. The child, however, soon tires of the bitter taste,
and its continued use will always stop the habit. Biting the finger-
nails may likewise be remedied by the use of these bitter solutions.
The most pernicious habit, masturbation, is referred to on page 433.
It is surprising in how many ways children will develop habits
of manipulating different parts of the body. One of my most
troublesome cases was in a child one year old who came to me with
an ear stretched to twice its normal size. During the greater part
of its waking hours the child grasped and pulled at the top of the
left ear.
MASTURBATION 433
Another case was in a patient who was brought because of the
habit of burrowing the right thumb into the right nostril. The
nostril had become stretched to at least three times its normal
size, causing a most peculiar deformity.
It is impossible to make other than general suggestions for the
correction of bad habits in children. When there is manipula-
tion of the mouth, the sense of taste can usually be made to aid
us. In other instances restrictions of a mechanical nature may
be necessary. In the ear-pulling case, a tight-fitting muslin cap
was worn constantly and the right hand kept pinned to the clothing.
Punishment, rewards, and ridicule, all may be effectively used in
the treatment of these cases. Regarding bad habits as to hours
for feeding and sleeping, as well as the habit of carrying a child
in arms — all may be corrected by doing the right thing at the right
time and having a sufificient amount of courage to persist in it. It
is to be remembered that, regardless of its age, a child is never
harmed by rigid discipline properly applied.
MASTURBATION
Before the fifth year a great many more cases of masturbation
are seen among girls than among boys. After that age it is more
frequent in boys. The most common means of practising mastur-
bation in either sex in infancy is by leg-rubbing. Contact by means
of the edge of a chair or the corner of a sofa or any object against
which pressure may be exerted is not infrequently the means
used in older girls. Manipulation of the parts, while only occa-
sionally seen in girls, is the usual method in boys after the third
year. My youngest case was in a female child six months of age
who was a "leg-rubber," and who evidently passed through a com-
plete orgasm. In many the habit will be indulged in several times
a day.
In boys the primary causes of the practice, other than that of a
neurotic habit, are an elongated foreskin, adherent prepuce, and phi-
mosis. The handling of the parts necessary to keep the uncircum-
cised clean is an exciting factor. In girls, vulvitis and vaginitis,
with their resulting irritations, which are not relieved by cleansing
and keeping the parts dry, are frequent causes. It is a popular
notion that thread-worms may be an exciting factor; but among
many cases of masturbation and many cases of thread-worms I have
never seen both in the same child.
Prophylaxis. — Masturbation is much easier to prevent than cure.
In boys, prevention lies in having a clean, free glans, which in the
great majority of male infants can be obtained only after proper sur-
gical procedures. The elongated, thickened, uncut portion of the
foreskin usually seen below the glans after a ritual circumcision is
but Httle better than a free, elongated prepuce. The sHtting of the
28
434 HEREDITY AND ENVIRONMENT
foreskin which is sometimes produced by the so-called dorsal slit
gives results very similar in character to a long, redundant foreskin.
In girls, prevention in a certain degree rests in keeping the parts
clean through washing them once a day with great gentleness, and
the free use of non-irritating absorbent powders. A powder com-
posed of equal parts of powdered starch and oxid of zinc gives very
satisfactory results.
With the habit of masturbation once established, the first step
is to eliminate the cause, if it can be discovered, and put the parts
in a normal condition. Circumcision in boys, releasing the adhesions
to the clitoris in girls, with cleanliness and as Uttle manipulation
as possible, are absolutely essential.
• The urine should be examined, and if found highly acid, it should
be corrected by diet and by the use of bicarbonate of soda, from
six to twelve grains being given daily, according to the age of the
patient. If red meat has formed a considerable part of the diet,
Fig. 50. — Knee-crutch.
the quantity should be reduced and given not oftener than three
times a week.
Having removed all possible sources of local irritation, we are
in a position to use restrictive measures, as it is through such treat-
ment only that a cure will finally be effected. If the practice is
prevented the habit will soon be forgotten. The older the child,
the more difficult will be the cure. The restrictive measures em-
ployed depend to a considerable extent upon the age, sex, and
method of practice. In young children of both sexes who practise
leg-rubbing, a large napkin of some coarse material, or a towel,
is placed over the napkin usually worn, and applied in the same
way, so as to keep the legs widely separated. After the napkin
age a large towel may also be used, if necessary, for the same pur-
pose, or the knee-crutch (Fig. 50) may be employed. Some children
will indulge only when in a certain chair or in a certain posi-
tion.
MASTURBATION
435
Illustrative Cases. — A very troublesome case in a girl seventeen
months old was treated without success for several weeks, when I
discovered that the child practised the act only when in her high
chair, as by leaning forward and grasping the projecting arms she
managed to bring the necessary pressure to bear upon the genitals.
The use of the chair being discontinued, there was no further trouble.
Another child, a girl six years of age, was an inveterate mastur-
bator. She had been treated by several physicians. The act was
repeated daily, sometimes two or three times a day, usuallv by con-
tact, such as by pressure against the corner of a table, sofa, or chair.
?RACE Used to Prevent Mantai. Masturbation.
When in bed, she indulged in the practice by manipulation. She had
become pale, thin, and hysterical, and being a member of a promi-
nent family, great concern was felt for her. It seemed that here
was a case where eternal vigilance was the price of safety. The
external genitals were congested and swollen as a result of the
direct irritation, otherwise they were normal. The gravity of the
condition was apparent, and the parents readily agreed to my sug-
gestion that the child should never be left alone. The mother
and the nursery maid took turns in being with the child in the
daytime. A trusty middle-aged woman was selected for the night
436 HEREDITY AND ENVIRONMENT
watch. I directed that no reference be made to the habit, but that
the child should be severely punished if the practice was attempted.
This, however, was not needed. This child, as is the case with all
older children, masturbated in secret, and as she was never left
alone the practice was stopped. She was given suitable food,
teaching by a visiting governess was begun, and hard play was
soon advised, as her physical improvement was rapid. As there
was no further tendency to masturbate, the night watch was reUeved
after six months. The child was kept under the closest observation,
however, for a much longer time. Cooperation to such a degree
as in this family can, however, rarely be secured.
Older children who practise manipulation of the parts can usually
be watched during the daytime, but the habit is apt to be indulged
in on going to bed, after the lights are out, and in the early morning,
particularly when it is prevented during the day. In such instances,
I have been obUged to advise mechanical restraint. An inexpensive
and effective means is to use a piece of tape, which is tied in the
center around the child's neck in a flat knot, leaving the two ends
long enough to be securely tied around the child's wrists, so as to
allow a free movement of the hands above the umbilicus. The
child can use the handkerchief, and adjust the bed-clothing, but
cannot touch the genitals. If the patient is a girl and a mastur-
bator by contact with any object, or a leg-rubber, a large bath-towel,
if worn like an infant's napkin, will aid materially in discouraging
the practice. A brace (Fig. 51), constructed of steel, with a hinge-
joint to allow the arm to be extended to an angle of about 45 de-
grees, has been used with success in a few cases. This brace is worn
only at night.
CONSTITUTIONAL DISORDERS
ICTERUS— OBSTRUCTIVE JAUNDICE
Jaundice of this type in children is usually associated with
duodenitis and is caused by a swelHng of the mucous membrane
of the common bile-duct at its terminal opening into the intestine,
and is due probably to the same form of infection that caused the
duodenitis. I have seen but one case in which the jaundice was
due to cholelithiasis — that of a girl six years of age. The patient
had distinct attacks of biliary colic with passage of gall-stones and
followed by intense jaundice. She was operated upon later and
many stones removed from the gall-bladder.
The onset of my cases has been almost invariably without high
temperature, or the evidence of severe gastric disturbance. Usually
the first sign that something is wrong with the child is a loss of
appetite, a degree or two of temperature, a coated tongue, and
listlessness. The yellow discoloration of the conjunctivae and the
skin soon appears, which with the high-colored urine and slightly
colored or grayish stools makes the case complete.
Treatment. — Diet. — The reason why gastric disorders are consid-
ered so prominent a symptom by many writers is possibly because
of the gastric disturbance produced by their treatment. We are
advised to place the patient on a milk diet and give calomel. I
know of no treatment better calculated to produce vomiting and in-
crease both the intestinal infection and the jaundice. The treat-
ment which I have found most satisfactory is the use of very little
food for twenty-four hours. Water is given as a drink and chicken
or mutton broth well salted may be given with toast later if the
child asks for food. He should not be urged to eat. The following
day, broths, gruels, and orange-juice, with stewed fruits or lemonade,
are given if the child wants them.
Drugs. — The only medication used consists of rhubarb and soda.
To a child five years of age I give foul grains of pulverized rhubarb
and eight grains of bicarbonate of soda from two to three times daily,
giving at the same time considerable water. For a day or two suffi-
cient should be given to produce a free laxative effect, but not neces-
sarily to purge the patient. Usually on the third day I begin with
tincture of nux vomica and dilute hydrochloric acid — from two to
four drops of each, well diluted. With the return of the stools to
the normal the usual diet may be resumed, milk not being given
for a week afterward. Rhubarb and soda are best given as follows :
437
438 CONSTITUTIONAL DISORDERS
I^. Pulveris rhei gr. xlviij
Sodii bicarbonatis gr. xcvj
Syrupi rhei aromaticae §j
Aquae q. s. ad ^ij
M. Sig. — Shake well. Give one teaspoonful two or three times
daily after meals.
OBESITY
Exceedingly fat children will usually be found to be large eaters
and of inactive habits. It is rarely a serious condition and ordi-
narily requires little more than certain restrictions in diet and
regularity in exercise. Generally this is not difficult to obtain, as
the patient is usually very anxious to reduce the weight because
of the attention he attracts and the remarks the condition occasions
in pubHc places and among school-fellows.
Treatment. — Diet. — In such cases I direct that all fatty foods,
including butter and milk, be excluded from the diet. Skimmed
milk may be given in moderation — not over one pint daily. It may
be used on the cereal, and eight ounces may be given as a drink if
the child is fond of it. The use of sugar, including candy and sweets
of all kinds, is forbidden. Saccharin dissolved in the milk is used on
the cereal and in making stewed fruits and plain puddings palatable.
Exercise. — During the warmer months, golf, swimming, tennis,
horseback exercise, and the bicycle are advised, a definite time,
in hours, being prescribed each day for some active physical exercise.
During the cold months, roller-skating, ice-skating, horseback-riding,
out of doors when possible and indoors on inclement days, when the
means are at hand, together with long walks, are a part of the daily
life. A schedule is prescribed and written out for each day, depend-
ing somewhat upon the station in life of the patient, not only as
regards food but also as regards outdoor exercise. In this way, by
estabhshing a system of living covering the entire day, there will
result, if the family cooperate, a reduction of the obesity with a
marked improvement in the patient's general condition.
Drugs. — The use of thyroid extract and other drugs for the reduc-
tion of weight in children is not to be advised.
During the treatment the child should be weighed regularly, as
too pronounced results are not desired.
THE ANEMIAS OF INFANCY AND CHILDHOOD
A description of the treatment of the various forms of anemia
as seen in the young, would be a repetition to a considerable extent
of the management of malnutrition. Every child with anemia
suffers to a certain degree from malnutrition also. The etiology
of practically all the severer blood diseases in children, such as chlo-
rosis, leukemia, the pseudoleukemic anemia of Van Jaksch, and perni-
cious anemia, is but little understood.
Treatment. — Cases of secondary anemia must be treated along
THE ANEMIAS OF INFANCY AND CHILDHOOD 439
symptomatic lines. Disordered intestinal digestion with its result-
ing toxemias and systemic poisoning, which are also little under-
stood, doubtless plays a major role in the blood diseases. The
management of anemia in the young resolves itself into a cor-
rection of existing digestive errors. The bottle-fed baby suflfering
from a grave form of anemia is given a better chance for recovery
if he is placed on the breast. A wet-nurse should alwavs be se-
cured, if possible. When this is not possible the child's food should so
be arranged as best to fit his digestive capacity, remembering that
as high a proteid as is compatible with digestion should be given.
These children also require all the advantages furnished by bathing
and fresh air. An indoor airing (page 37) for hours at a time
should always be given these children when they cannot be sent
out of doors. The sleeping apartment should always communicate
with the open air. If the patient is of school-age, the time when
we see most of the secondary anemias, he should be allowed to attend
only the morning session and be forced to rest for an hour or two
after the midday meal. While exercise and play are necessary,
they should not be allowed to the point of fatigue. More clothing
will be required, both in winter and summer, than is needed for well
children of the same age in the same climate. Among my dispensary
patients I see a goodly number of these cases. I insist that the child
shall occupy the sleeping-room alone and direct that the living-
room or "parlor room," as it is sometimes called by these people,
be used as the sleeping-room of the patient. If the parents are suffi-
ciently well-to-do to send the child to the country, this is advised.
As with all forms of malnutrition in children, the diet, when
there is an associated anemia, is most important. A high-proteid
diet should be given; red meat at least once a day, poultry, fish,
eggs, milk, and butter; oatmeal, cracked wheat (each cooked three
hours), together with the legumes and potatoes, should form the basis
of the dietary. Better results, I find, are obtained by selecting foods
that are rich in iron than when inorganic iron is given as medicine.
The following table of Bunge may be of assistance in the selection
of food for anemic children. It gives the number of milHgrams of
iron in the dried substances:
Corn
Wheat flour
1.0
-2.0
1.6
2.3
-3.1
3.7
3.9
4.3
4.5
4.9
4.9
5.5
5.7
6.4
Peas
Black Cherry
.... 6.;
2-6.6
7 2
Bovine milk
'.'.'.'.'.2.3
8 3
Human milk
Carrots
Strawberries
Lentils
Red Cherries.
8.6
Raspberries
9 5
Hazelnuts
10 0
Barley
Almond
Rye
Wheat
Apples
Beef
Asparagus
Yolk of egg. .
10 0-
13.0
17.0
20.0
-24 0
Buckwheat
Potato
Spinach
....33.0-
-39.0
44© CONSTITUTIONAL DISORDERS
It will be seen from the foregoing that the diet of many "run-
about " children, viz., milk and the products of wheat flour, such
as white bread, crackers, and cake, are substances comparatively
poor in iron, and this doubtless helps to explain many of the anemias
found at this age among the poorer classes.
Iron. — In a great majority of instances in which iron is given
to children it is used indiscriminately, in too large doses, and usu-
ally without benefit. It is doubtless prescribed, on general princi-
ples, more frequently than any other drug. I am yet to be convinced
that it possesses any great value in the blood disorders in children
other than chlorosis. Of this I am certain : when it is given without
suitable attention to nutrition, digestion, bowel function, and general
hygiene, iron is of no benefit, and is more frequently harmful, because
it is very apt to increase the defective intestinal elimination, a con-
dition usually present in anemia. The blood of the average child
three years of age contains at the most only about six grains of iron.
The advantage of prescribing three or four grains daily for a child
of this age should hardly be considered. My results in secondary
anemia have usually been satisfactory without iron when the pre-
scribed diet and hygienic regulations were carried out. Iron is
useful, however, in selected cases of anemia and of considerable
service in chlorosis.
In the selection of preparations of iron, those which are least
irritating to the stomach, and the least constipating, should be
chosen. With this in view, the citrates should be selected if the
drug is to be given in liquid form. They are soluble in water
and produce less digestive disturbance than do the other forms.
The citrate of iron and ammonia and the citrate of iron and quinin,
particularly the latter, have been found satisfactory. The dosage
for a child two years of age or older is one grain, which is best given
in sherry wine after meals. Where a patient can swallow a pill or
a capsule, the extractum ferri pomatum in doses of from j to ^ grain,
three times daily, alone or combined with nux A^omica or quinin,
will benefit the patient as much as iron is capable of. If the anemia
and malnutrition are due to a remote congenital syphilitic infection
(page 393), bichlorid of mercury in small doses — ^-q to -^j^ grain,
three times daily — is often productive of marvelous results. To
my young patients suffering from malnutrition, particularly those
in whom I am not certain of the family history, I often give mercury
in order to make a diagnosis more certain.
Chlorosis occurs in young girls about the time of puberty or
later. It is a disease in which drugs are given with most satis-
factory results. Here iron and arsenic do good service, although
I have seen cases which showed no improvement under medication
make complete recoveries after a change of food and place of residence
from the city to the country. Among the various lines of medica-
RACHITIS 441
tion I have found the following combination the most service-
able:
I^. Tincturae nucis vomicae gtt. cxx
Extracti cascarae sagrad^e gr. x
Extract! ferri pomati gf- xv
Liquoris potassii arsenitis gtt. cxx
QuininEe bisulphatis 5j
M. div. et ft. capsulae No. xxx.
Sig. — One after each meal.
This is given for ten days, and repeated after five days' inter-
mission. Interrupted medication is thus continued until recovery
follows or until it is demonstrated that other drugs must be used.
A patient with chlorosis should have all the advantages of diet and
change of scene that the circumstances of the family will permit.
RACHITIS
Rachitis is a disease of nutrition, and is peculiar in that a greater
part of the structures which make up the infant organism are in-
volved in the rachitic processes. The bones show the character-
istic deformities, the most common of which are the enlarged
epiphyses, the square head, the open fontanel, the beaded ribs, and
the lateral chest curves. The muscles are undeveloped and flabby,
the mucous membranes are prone to catarrhal inflammations, and
the nervous system shows a lack of development; rachitic children
being particularly susceptible to disorders, such as laryngismus
stridulus and infantile convulsions. Rachitic children are inva-
riably anemic. Dentition is delayed, and when the teeth appear
they are apt to come in groups of four or more at one time and
occasion no little disturbance. Repeatedly it happens that the
first teeth are not cut until after the fifteenth month. Rachitic
children are late in walking, suffer from constipation, and are usually
below the average weight and size; in short, a child with rachitis
is unique in the sense that he is constitutionally below the normal
in every respect as regards growth, development, and resistance
to untoward influences. The rachitic child is an easy mark for
any disease which may be prevalent, and while rachitis itself is not
a fatal disease, it contributes no small part to infant mortality
because of the low vitality which is characteristic of the condition.
Bronchopneumonia, pertussis, and the gastro-enteric affections are
all very dangerous in rachitic infants. Italians and the colored
race are particularly stisceptible to the disease. While well-marked
rachitis is rare before the sixth month, infants two or three months
of age show the beginning characteristic changes in the muscles and
bones.
Much has been written regarding the etiology of the disease in
its relation to climate and unhygienic surroundings, and while
such surroundings may contribute to the result, I have yet to be
442 CONSTITUTIONAL DISORDERS
convinced that as etiologic factors they are very important. It
is true that we usually find rachitic children with unhygienic sur-
roundings, but thousands of others who live under the same condi-
tions do not have rachitis. A child fed on normal breast-milk
will endure much that is not hygienic and still not develop
rachitis.
In the treatment of several thousand rachitic children, one fact
has impressed me most strongly: Given a child suffering from
rachitis, we have a child suffering from nutritional errors as a result
of improper feeding, or an inability to assimilate a suitable food;
and I have yet to see a case which did not improve when suitable
nourishment could be given, and assimilated, regardless of the age
of the patient. In children under one year of age the feeding of
the proprietary foods or condensed milk is the most frequent cause
of the disease. The next most frequent cause is the feeding of a
too strong cow's-milk mixture, which produces indigestion and
faulty assimilation. Breast-fed babies among the Italians and
negroes occasionally have rachitis, and an examination of the breast-
milk will invariably show a diminution of one or more of the nutri-
tional elements — usually the proteid.
A nursing woman in the New York Infant Asylum had such
a free flow of milk that a foster-child was given her to nurse. The
children failed to thrive; each made a gain of but two or three
ounces weekly; both developed rachitis, one in a marked degree.
Repeated examinations of the breast-milk showed it to contain
1.5 percent fat, 4 percent sugar, and 0.5 percent proteid.
After the first year fewer cases develop, but a late rachitis is
bv no means uncommon. In my own cases the development of
the disease at this age and after, as in the very young, has been
distinctly traceable to faulty feeding and faulty digestion. Not
a few cases between the second and third years were considered
due to prolonged nursing. I have known just two mothers who
could nurse their children, and substantially nourish them, by
the breast later than the twelfth month. Usually when the breast
furnishes the only means of nourishment after the first year of life,
a beginning rachitis will soon be noticed. The feeding after the first
year of an exclusive diet of milk or of indigestible starches is not in-
frequentlv a cause of rachitis. Among the poorer classes children
during the second and third years are almost always badly fed.
The diet usually consists of poor milk and poorly cooked starches.
Children thus fed furnish no small part of our rachitic patients.
Treatment. — It will readily be seen from the foregoing that the
treatment of rachitis resolves itself into the adjustment of the diet
to the needs of the patient. As growth and normal development
cannot take place without proteid, and as the history of our cases
has shown that this is the element which is most frequently lacking
RACHITIS 443
in the diet of rachitic children, the feeding of the proper amount of
proteid should be our first consideration.
The artificial foods and condensed milk are deficient in that in
them both the fat and the proteid are low; therefore these foods
should be discontinued and a properly adapted cow's milk substi-
tuted. This appUes to children under one year of age. In a great
many cases this is the only treatment required.
Diet. — -For those over one year of age, not only should the arti-
ficial food be discontinued and cow's milk given, but the cow's milk
should be supplemented by a diet rich in nitrogen. I order a diet
composed largely of milk, scraped beef, soft-boiled egg, oatmeal, and
wheat gruel. After the second year purees of beans and peas are
added to the dietary because of the large percentage of proteid
which they contain. It is impossible to prescribe a more definite
dietary. The physician must remember that a diet as highly ni-
trogenous as the child can assimilate is to be given. Unfortu-
nately, many rachitic children cannot take cow's milk in quantities
sufficient to make it of real nutritive value. This is often the result
of an inability to digest the fat, the milk being taken without incon-
venience when a large proportion of the fat is removed. Skimmed
milk contains at least 3 percent of the chief nutritional element, the
proteid, and makes a valuable addition to the diet. If a dilution of
the milk is necessary, oatmeal gruel should be used.
Many children who cannot take a full milk diet will take an
ounce or two of butter daily without inconvenience. In older
children I advise the free use of butter, one or two ounces daily.
It is advisable to give rachitic children a moderate amount of fat,
as it aids in the production of heat and thus saves the tissues. In
children under one year of age cod-liver oil is often a valuable ad-
dition to the dietary. In prescribing cod-liver oil I prefer to use
the plain oil. In spite of the disgust adults have for cod-liver oil,
children usually take it readily. The younger the child, the better
the oil will be taken. For delicate children six months of age,
from ten to thirty drops may be given three times daily after meals.
From the sixth to the eighteenth month, from twenty drops to
a dram may be given three times daily after feedings. After the
eighteenth month from one to three drams may be given three
times daily after meals.
Hygiene. — Brine baths and oil inunctions aid materially in im-
proving the child's condition as a whole, and are of great value. The
brine bath (page 31), which is given at bedtime, is followed by an
inunction of goose grease, unsalted lard, or cacao-butter. The goose
oil or the lard is preferred. At least two teaspoonfuls should be
rubbed into the skin. The benefit derived from the inunctions
is largely due to the massage. The rubbing should be continued
for at least ten minutes; the muscles of the back and legs should
444 CONSTITUTIONAL DISORDERS
receive special attention. In a few children the animal fats act
as irritants to the skin and produce a fine papular eruption.
The rachitic child should have plenty of fresh air, by means
either of a fire-place or an open window. On stormy and very cold
days he should be given an indoor airing (page 37), being placed
in his carriage or cart and wheeled about the room, and, to avoid
drafts, the window or windows on only one side of the room should
be opened.
Rachitic children are very susceptible to head colds and bron-
chitis; therefore every means must be employed to prevent ex-
posure. As creeping and playing on the floor are the most frequent
ways for a child's taking cold, the exercise pen (page 37) is par-
ticularly useful in these cases.
Drugs. — Drugs in my experience are of value only as they in-
crease the appetite and the capacity for properly selected foods.
The administration of phosphorus is without avail if the deficient diet
is continued. Specific medication without proper food and a fair
digestive capacity is valueless. With proper food and a fair digestive
capacity, medication is superfluous, and a child rapidly recovers
without it.
Phosphorus I have used extensively and have yet to see a single
case in which the beneficial action of the drug could be proved.
In giving phosphorus, the oleum phosphoratum is the easiest and
most convenient method of using it. One drop of the preparation
represents y^'o grain of phosphorus. For children under one year
of age, one drop may be given three times daily. For those between
the first and second year, one and one-half to two drops may be
given three times daily after meals.
Deformities. — The deformities of the osseous system, particularly
of the spine and the long bones, may be prevented — the first, by
keeping the child on his back a greater part of the time, and if the
deformity is well marked, by teaching him to sleep resting on his
stomach. When kyphosis is present the child should be allowed to
remain in the upright position but a few moments at a time.
Deformities of the femur, tibia, and fibula occur long before
the child attempts to stand, but too early use of the legs, while not
necessarily a cause of deformity, may greatly aggravate the existing
conditions. For this reason rachitic children should not be encour-
aged to walk or stand until they have been under treatment for
three or four months.
Operative measures for the correction of bow-legs are better
postponed until after the third year. If done at an earlier period
the deformity is apt to return, and the late deformity may be greater
than the original one.
In my experience, the use of braces to correct the deformity of
the legs has been of but little assistance, nor has any patient of
SCORBUTUS. SPORADIC CRETINISM 445
mine been benefited particularly when so treated by the ortho-
pedic surgeon. The use of braces and jackets of plaster-of- Paris in
kyphosis is usually unnecessary. Rest, massage, and exercises di-
rected to restore power to the weakened muscles have answered
well in my cases.
SCORBUTUS— SCURVY
Inasmuch as scurvy is a disease caused by improper feeding,
the management is largely dietetic. Sterilized milk and the pro-
prietary meal foods are responsible for a great majority of the cases.
Treatment. — Dietetic. — The first step in the treatment is to supply
fresh milk for the child, diluted, if necessary, to meet its digestive
capacity. I have seen cases in which the diagnosis was made early
completely recover under a change from sterilized milk to raw milk,
without the aid of any other measure. Inasmuch as the disease is a
most painful one, every means possible should be employed toward
furnishing early relief. Orange-juice is a specific for the disease. The
child takes it greedily. One teaspoonful may be given at two-hour in-
tervals, one ounce being given ordinarily in twenty-four hours. Un-
less the case is an advanced one, with extensive subperiosteal hem-
orrhages and separation of the epiphyses, relief will be noticed in
twenty-four hours and an entire cessation of symptoms in from
five to seven days. I have seen a few cases entirely relieved at
the end of seventy-two hours of treatment. These were in infants,
in whom the diagnosis was made very early — the only symptom
being the evidence of pain during manipulation of the limbs in
bathing or while changing the napkin, this is usually the first sign
of the trouble.
Illustrative Cases. — A case of long duration under treatment was
in a boy eighteen months of age, who had been on almost an ex-
clusive diet of a malted proprietary food from birth. The illness
had existed for two months with extensive subperiosteal hemor-
rhages and required three months of treatment before it could be
considered well. In a comparatively recent case in my service at
the Babies' Hospital, in which there was separation of the epiph3^ses
of the humerus at the shoulder and of both femurs at the hip, three
weeks were required to effect a cure.
The management of more severe cases is the same as of those
of milder type. Fresh food with orange -juice or beef -juice must
be freely given. The patients should be handled very gently and
only when necessary, as the pain on manipulation of the involved
parts is most excruciating.
SPORADIC CRETINISM— INFANTILE MYXEDEMA
Sporadic cretinism is due to an absence of, or to a derangement
of function of the thyroid gland. In cretinism there is an arrest
of mental and physical development, the latter being of a character-
446 CONSTITUTIONAL DISORDERS
istic type with retarded growth and developmental anomalies not
seen in any other condition. Without treatment the cases which
live through infancy become dwarfs and idiots.
The Thyroid Treatment. — The specific treatment is the thyroid
treatment. The most pronounced beneficial results of this treat-
ment are noticed when it is brought into use early in life. The
diagnosis of cretinism is rarely made before the fifth or sixth month,
oftentimes much later, for the reason that the case does not happen
to come under the observation of those competent to diagnose it.
Illustrative Cases. — In two of my cases the patients were first
seen by me, one at the fifth, the other at the seventh month. Other
cases have been treated in institution and in private work; the
two referred to, however, were seen earlier and almost daily for
months, consequently there was an excellent opportunity for observ-
ing the effects of the thyroid administration. A fairly complete
history of one of the cases is as follows: The desiccated thyroid
extract of Parke, Davis & Co. was used. At first it was given in
one -half-grain doses twice daily. The beneficial effects were noticed
in three days. The first change for the better was observed by
the mother, who stated that the child seemed warmer and that less
bed-clothing was necessary. The next positive change occurred,
according to my records, on the fifth day of treatment. The child's
general condition was very much improved. Her extremities were
warmer, her color was better, and she commenced to move her
arms; but what particularly impressed the mother was that less
bed-clothing v/as needed to keep the child warm. At about the
seventh day of treatment the patient cried vigorously when dis-
turbed in changing the napkin, something which she had never
done before. She had previously been stupid and apathetic.
The next and rapidly following changes for the better, were that
the patient noticed and appeared interested in her mother and
followed her with her eyes about the room, and while previously
she had rarely used her legs or arms except when disturbed, she
now began to move them about voluntarily ; as the mother expressed
it: "The child had acted as though she were under the influence
of some powerful depressant drug whose effects were gradually
wearing off." When the child was five and one -half months old,
after she had been under treatment for sixteen days, receiving
one-half grain of thyroid twice daily, she smiled for the first time.
She cut the first tooth at the ninth month and walked alone at the
fourteenth month. She is now, at two years of age, taking three
grains daily, and is apparently normal in every respect.
Dosage. — The increase in the thyroid administration must be deter-
mined by the condition of the patient. As long as progress is shown
in more active and normal mentality, with an increase in the growth
of the long bones and a gradual loss of the typical facial and other
SPORADIC CRETINISM
447
characteristics, it is unwise to increase the dosage of the thyroid.
When, however, a period arrives when no progress appears to be
made, the daily dosage should gradually be increased by one-half
grain. Evidences of overdosage are pallor, prostration, perspira-
tion, and indigestion. When any of the above signs present them-
selves, it is an indication to discontinue the medication for twentv-
four hours and then resume with smaller doses.
When the child in whom treatment was commenced at the
seventh month was nine months of age, it was found necessarv to
give one-half grain three times daily. One month later, one-half
grain was given four times daily. At this time the child could sit
up and hold the head erect. The increase in the thyroid extract
produced vomit-
ing, and the dosage
of one-half grain
three times daih^
was resumed. One
year after the com-
mencement of the
treatment, when the
patient was nine-
teen months old,
two grains daily
were required.
In both of these
infants the protru-
sion of the tongue
was one of the
latest symptoms to
disappear.
My cases have
varied considerably
as to the amount of
thyroid required. The dosage used was that taken by those in whom
the disease was discovered very early in life. The older the patient
when the thyroid is begun, the less marked the beneficial results.
I have a Httle girl five years of age under treatment at the present
time who came under my care two years ago, weighing fifteen pounds
and three ounces. She made a marvelous improvement under
one-half grain twice a day, which in two weeks was increased to one-
half grain three times a day. This we were obliged to decrease
because of the prostration and perspiration which it appeared to
occasion. The dosage of one-half grain three times daily could not
be used until she was four years of age. She is now five years
old and requires one grain three times a day. In this child the
most remarkable improvement was noted. (See Figs. 52 and 53.)
Fig. 52. — Cretin, before Treatment.
448 CONSTITUTIONAL DISORDERS
The interval of time between the photographs was thirty-four days.
Six teeth were cut in three weeks after beginning the treatment and
sixteen more were cut during the next six months. The child made
corresponding improvement in every other respect.
For another case, a nine-year-old girl, who is now normal in
every respect except that her hair is rather coarse with a tendency
to dryness of the scalp, it was found that the following amounts
of desiccated thyroid were required at the various ages :
Six months U grains daily-
One year 3 J
Two years 5 " "
Three years 8 " "
Four years 8 " "
This patient both walked and talked at fifteen months. In her
case, in order to deter-
mine what the effects of
the withdrawal of the
treatment might be, the
thyroid was discontinued.
This was first attempted
when she was two and
J - l^^r one-half years of age.
m ' ^ '-• V - JIf '^^^ mother was asked
fl^^ ff to keep close watch of
r W S her in order to detect
the slightest difference
in her behavior. After
three days without thy-
roid it was noticed that
the child became less ac-
tive and disinclined to
play. She was not irri-
table or cross, but would
Fig. 53-— Cretin, after Thyroid Treatment. sit in her Httlc chair the
entire day. She had pre-
viously been very bright, active, and talkative. A few days later
she ceased to talk voluntarily and answered only when spoken to.
After twelve days without thyroid it was resumed, and her activity
again returned. About one year later a similar trial was attempted
with similar results, although the duration of the test was shorter, as
the mother, who was a dispensary patient and had had the thyroid
furnished her, purchased a bottle of tablets and gave them on her
own responsibility. The child, now nine years old, is taking twelve
grains daily. She is a normal, healthy school-girl, alive to all in-
terests of girlhood, and no one in the village where she resides, out-
side of the family circle, knows that she is a cretin.
«^
STATUS LYMPHATICUS. PURPURA 449
STATUS LYMPHATICUS
Status lymphaticus is an unusual condition in which the lymph-
atic tissue throughout the body is in a state of hyperplasia.
The condition is usually associated with marked rachitic manifesta-
tions. The chief interest attaching to the disease lies in the dan-
ger of sudden death of those so affected and in the danger from
the administration of an anesthetic, particularly chloroform. The
lymphatic glands and the thymus are the parts particularly involved.
Laryngismus stridulus and thymic asthma are frequent manifestations
of the condition. It may exist, however, without the occurrence
of either. The nature of the condition is not known. The cases
which I have seen, a considerable number, were all sufferers from
chronic intestinal indigestion.
Illustrative Case. — In one case, a boy five months old — a
most difficult feeding case — there were from twenty to thirty
attacks of laryngismus stridulus in twenty-four hours. Two
trained nurses were in constant attendance. The entire duration
of the seizures covered a period of two months. The marked fre-
quency of the attacks continued for less than a week. The boy
eventually recovered. When he was four years of age I removed
both tonsils and adenoids under ether anesthesia without any
unfavorable effects from the anesthetic.
The most we can do with these patients is to improve their
general condition along common-sense lines in relation to nutrition,
rest, and exercise, as described in the section on The Delicate Child
(page 142). Excitement and stress of any kind are to be avoided.
In most instances the condition disappears under improved nutri-
tion and a well-ordered life.
PURPURA
By purpura we understand that condition in which the blood,
having escaped from its natural channels, becomes localized in dif-
ferent portions of the skin and subcutaneous tissue with no constant
change in the character of the blood or demonstrable lesion in the
vascular wall. Purpura associated with scorbutus and peliosis
rheumatica has been referred to elsewhere. Among the other forms
met with, the difference appears to be largely one of degree, and
is due to toxic conditions of various kinds. It may occur late in
an exhaustive disease. Petechiae in the skin are frequently seen
at the close of many of the exhaustive diseases, particularly in entero-
colitis. Purpura may result from the administration of drugs.
Illustrative Cases. — One of my patients two years of age devel-
oped a mild purpura while taking large doses of antipyrin, which was
being administered through a misunderstanding. In pyemia, pur-
pura is not unusual. In a patient nineteen months of age, w^ho died
29
450 CONSTITUTIONAL DISORDERS
from a septic sinus thrombosis with extension to the jugulars, there
was extensive purpura for forty-eight hours before death. Blood ex-
aminations of this patient during life showed pure cultures of strep-
tococci. Another patient, a boy eight years of age, previously
healthy, died in three days from purpura fulminans (Henoch). In
this case also, blood cultures made post mortem, from subcutaneous
hemorrhagic areas, showed pure streptococci. In the severe forms
of purpura the hemorrhage is not confined to the skin, but occurs
from the mucous surfaces or in the viscera.
Treatment. — The treatment consists in establishing the vitality
and resistance of the patient, in removing the cause when possible,
and in the internal administration of acids and fruit-juices. The
internal use of drugs, including the suprarenal extract and ergot,
has not been of apparent value in my cases. In purpura fulmi-
nans the prognosis is necessarily very grave. When it develops in
severe septic conditions or in prolonged exhausting diseases it is a
symptom of much gravity. In these cases, the free use of alcoholic
stimulation should be resorted to early, — one to two drams being
given every two hours to a child five years of age.
HEMOPHILIA
Hemophiha is characterized by a tendency to uncontrollable
bleeding following cuts and bruises. The cause of the condition
has not yet been discovered. Various theories have been put
forward from time to time. Heredity can be traced in most cases.
Daughters of bleeders should not marry, as their offspring are likely
to become bleeders, particularly' the male offspring.
Illustrative Case. — My personal experience deals with but one case,
a boy who was under my care the greater part of his life. The fact
that he was a bleeder was first suggested through hemorrhages into the
skin about the knee and arm which appeared as soon as he com-
menced to walk and to fall and bruise himself ; in fact, he was brought
to my clinic at the Babies' Hospital Dispensary because, as the
mother expressed it, he was continually black and blue. In all
other respects the child was normal; in fact, he was an unusually
strong, well-developed boy. Bleeding nearly caused his death
at different times during the second, third, and fourth years. A
sUght cut in the skin meant days of bleeding. One particularly
severe and prolonged hemorrhage occurred as the result of a fall
when a tooth pierced the lip. Having the boy under observation
for a long time and the assistance of an intelligent mother, we had
an opportunity to test the various means of medication and other
methods of treatment as suggested by different authors. Suffice
it to say that all measures, both general and local, were without
the slightest benefit. The only means of controlling the hemor-
rhage was by the use of strong pressure by means of pads and sur-
HEMOPHILIA
451
geon's adhesive plaster. The pressure had to be exerted not only
over the bleeding area but for several inches about it. The child
passed from under my care when about five years old, but I learned
that he died soon after from the operation of circumcision, which
was necessitated by the sloughing and sepsis of the foreskin. '
INFECTIOUS FEVERS
INFLUENZA
The management of influenza in a child is very similar to that
of measles. The disease in itself is rarely of suflicient severity to
cause any great concern. The possibility of serious complications,
however, is great; the younger the child, the greater the danger.
Treatment. — The disease is eminently contagious. Adults with
influenza should not come in contact with younger members of the
family. When one of a family of .children is attacked, the child
should be isolated as if he had measles or scarlet fever. The
patient should be put on a reduced diet (see Diet in Illness, page
133), and an initial dose of castor oil or one grain of calomel in
divided doses of one-sixth grain each should be administered.
The temperature, which not infrequently reaches 104° F. or
105° F., is usually readily controlled by sponging with alcohol and
water, one part alcohol and two parts water, at a temperature of
80° F. I have never been obliged to resort to the cool pack in
grippe. This, of course, should be done if the temperature is not
otherwise controlled.
The pain, the muscle soreness, and the restlessness are very
much alleviated by the use of phenacetin, caffein, and bicarbonate
of soda, given in powders as follows, to a child one year of age:
I^. Caffeinse citratis gf- ij
Phenacetin gf- v
Sodii bicarbonatis gr. x
M. Div. et ft. chart. No. x.
Sig. — One every two hours — eight doses in twenty-four hours.
In older children, those from two to four years of age, the following
may be used:
I^. Caffeinae citratis gr- iij
Phenacetin gr. x
Sodii bicarbonatis gr. xx
M. Div. et ft. chart. No. x.
Sig. — One every two hours — not more than six doses in twenty-four
hours.
After the fourth year, I have found it of advantage to give the
salicylate of soda instead of the bicarbonate. This, for a child
from five to eight years of age, will be as follows:
3^. Caffeinae citratis gr. iij
Phenacetin gr. xv
Sodii saHcylatis gr. xxx
M. Div. et ft. capsulse No. x.
Sig. — One capsule every two hours — a maximum of six doses in
twenty-four hours.
452
INFLUENZA 453
The salicylate is best given in capsule form, as most children at
this age may readily be taught to swallow a capsule.
So much for the medication of the uncomplicated grippe cases,
the duration of which is usually from three to five days. Such
cases occur in mild epidemics, in which the prominent symptoms
are fever, loss of appetite, headache, prostration, and muscle sore-
ness.
Illustrative Cases. — Two fatal cases of grippe in infants, in which
the diagnosis was made by exclusion and verified by autopsy, occurred
at the Country Branch of the New York Infant Asylum, during the
winter of 1888 and 1889, which, it will be remembered, was the time
when grippe first visited this country in epidemic form. These
healthy, breast-fed babies were taken with the disease together
with about forty other inmates — mothers and children — in ona
of the larger wards. The infants in question, aged three and four
months respectively, were stricken suddenly with high fever and
marked prostration. They quickly went into a condition of col-
lapse and both died in less than thirty-six hours from the onset.
The autopsy failed to show any pathologic change other than a
slight hypostatic congestion of the lungs.
Complications. — The most frequent complication of grippe is bron-
chitis, and the most fatal complication is bronchopneumonia. Sup-
purative otitis is not an infrequent complication, or perhaps it would
be better to class it as a grippe sequela. Among seventy-two cases
of acute suppurative otitis, seen by me during the past two years,
fifty-nine, or 81.9 percent, occurred with or followed immediately
upon an attack of grippe. Patients who, after an attack of grippe,
run a temperature without any apparent adequate cause, should
always be examined by a skilled otologist.
Occasionally grippe is ushered in wdth pronounced gastric dis-
turbance. There will be nausea and vomiting, no food being retained
for from twenty-four to forty-eight hours. Pronounced intestinal
disturbance is by no means an unusual evidence of infection with
the influenza bacillus; there may be diarrhea without any evidence
of involvement of the intestinal structure, or there may be a colitis
with tenesmus and mucus and blood in the stools. In not a few
cases the so-called complications are the only manifestations of the
infection. This has led writers to describe a "grippe colitis," a
"grippe gastritis," etc. I have seen two cases of endocarditis
associated with grippe.
Regardless of the way in which we interpret these various condi-
tions, one thing is to be remembered, that when the influenza bacillus
plays an important part in the infection, the successful management
of a case is rendered more difficult as relates to the ultimate recovery
from, and the duration of, the illness. After a severe so-called grippe
colitis, grippe bronchitis or pneumonia, the patient is left in a debil-
454 INFECTIOUS FEVERS
itated condition from which it may take weeks to recover. The
quickest way to remove this indefinable "grippe spell" which
rests over the patient is by a change of climate. Every late winter
and early spring, I send a goodly number of children to Atlantic
City. Two or three weeks there will do more to restore to health
New York city patients than I am able to accomplish with drugs,
baths, massage, and diet in an equal number of months at home.
I have repeatedly seen children with tracheobronchitis with a nag-
ging cough, which I had tried in vain to relieve, cease coughing
within a very few days after reaching that resort.
The management of an otitis, pneumonia, bronchitis, or colitis,
associated with or following an attack of influenza, differs in no
way, so far as the immediate treatment of the complication is con-
cerned, from that which would be advised if the case were inde-
pendent of the influenza bacillus. The case as a whole, however,
will require closer watching, and on account of the greater prostration
will need better feeding and freer stimulation.
One attack of grippe confers no immunity upon the patient ; in
fact, cases appear to reinfect themselves. For this reason, I always
advise that two rooms be used, one for the day and one for the
night, the room not occupied during the day being aired for several
hours with all the windows open. After recovery, the sick-rooms
should be thoroughly aired, cleaned, and fumigated with sulphur or
chlorin gas.
MALARIA
The presence of the plasmodium malaria in the blood in children
should always be demonstrated before making a diagnosis of malaria,
as in this way only can it be definitely determined that malaria
exists. Aside from the periodicity in the temperature rise, there
will usually be found in malaria an enlargement of the spleen; but
bevond this the symptoms are vague and indefinite. The diagnosis
of malaria is often made, and children are given quinin when the
condition does not exist. According to my observation, a periodic
rise in temperature which does not respond to quinin in full doses
is not uncomplicated malaria. There are very few exceptions to
this rule.
Children are very susceptible to fevers of a periodic type. Per-
sistent intestinal infection, otitis, encapsulated pus in the pleural
cavity, grippe infections, fatigue due to over-indulgence in play —
any one of these conditions mav give rise to an elevation of the
temperature more or less periodic in type, covering a considerable
period.
Quinin Administration. — When it is demonstrated that malaria
exists, quinin should be given in what might be considered large
doses, if we are to use the adult for comparison. Children tolerate
quinin well; in fact, to be effective, a much larger amount compara-
MALARIA 455
lively is required than in adults. In giving quinin to young chil-
dren, care must be used in its administration lest it excite vomit-
ing. I'^or this reason it should be given after meals in solution or
in capsule. The best menstruum is a preparation of yerba santa
known as yerberzine.' A child under eighteen months of age will
require from eight to twelve grains daily. Two to three grains of
the bisulphate should be given at a dose, not more than four doses
being given in twenty-four hours.
When resident physician at The New York Infant Asylum, then
located in southern Westchester County, New York, there was a
great deal of malaria among the women and children inmates. In
that institution I have repeatedly given infants under four months
of age eight grains in twenty-four hours. In some cases at this
age a larger quantity— ten to twelve grains — will be required.
Quinin chocolate tablets are sometimes used in giving the drug
to children. In using these tablets it must be remembered that
the quinin in them is in the form of the tannate, and that one grain
of the tannate represents about one-third of a grain of the sulphate.
In order to give sufhcient quinin in this form to be of value, the
large amount of chocolate in the tablet is sure to upset the digestion.
In children under one year of age with whom yerberzine may dis-
agree because of the sugar which it contains, the bisulphate may
be given in solution in distilled water, followed by a teaspoonful
of orange-juice. In older children — those from two to six years
of age — from fifteen to thirty grains daily will be necessary to con-
trol the disease. Here, as in the younger children, it is given in
yerberzine unless the child can be taught to take a capsule, when
it is given in three-grain doses at two-hour intervals until the pre-
scribed daily amount has been taken.
The giving of a large dose of quinin a few hours preceding the
expected chill does not answer well in children, as a large amount
given at one time is liable to cause vomiting.
The use of quinin by inunction or by the rectum has not been
satisfactory. Its use was so attempted at the Infant Asylum in
a great many cases where difficulty was experienced in the stomach
administration.
In but one case, aged two years, have I been obliged to resort
to hypodermic medication. The child showed the tertian parasite,
and the disease resisted the internal use of quinin in large doses,
but responded promptly to the muriate of quinin given hypoder-
matically, seven grains being used at one injection. There was no
abscess at the site of the injection and the child was permanently
cured. To be sure, the administration of quinin was continued by
the mouth, but the dosage of sixteen grains daily was now appar-
ently effective where previously it had made no impression.
' Made by Lilly and Co.
456 INFECTIOUS FEVERS
Recurrence. — The use of quinin in malaria should not be stopped
abruptly with a cessation of the fever. It is my custom to give
it in full doses for one week after the temperature fails to rise, unless
there is a subnormal temperature, in which event it is reduced one-
half or temporarily discontinued. It is a difficult matter to determine
when a case of malaria is cured. Time and again I have supposed
that a patient was well when a recurrence of the paroxysms took
place weeks afterward. How much of this was due to reinfection,
and how much to the old infection which had not been entirely
eradicated, is difficult to say. I am inclined to the belief, however,
that in many instances the plasmodium had remained inactive
in the spleen in spite of its return to nearly its normal size, for the
reason that the recurrence of symptoms sometimes took place
coincident with some other illness with fever, such as tonsillitis or
acute indigestion. My experience with recurrences of the disease
has been such that after an attack of malaria I now direct that the
child be given quinin for one week out of each month, for an indefinite
time, at least for a year following the original attack. In a com-
paratively recent case, a girl five years of age had repeated attacks
for two years before coming under my care. The mother was
instructed to give the child twelve grains of the bisulphate daily
for seven days out of each month. This, without a change of resi-
dence, was sufficient to prevent a recurrence during the fifteen
months which followed.
TYPHOID FEVER
Typhoid fever is a rare disease in New York city children under
two years of age. I have been able to prove but two cases in children
under one year. One was ten, the other eight months of age. The
diagnosis is often difficult because of the absence of the symptoms
seen in the adult. The younger the child, the more likely is this
to be the case. In neither of the above cases could we have been
positive of typhoid without the aid of the Widal reaction. While
usually the disease runs a shorter course in the child than in the
adult, an attack means, at the least, several days of illness, and it
may mean from three to six weeks. For this reason it is best to
establish a sick-room regime, under which must be particularly
considered the feeding, the bathing, the airing of the room, and
absolute quiet for the patient. The bed-linen should be changed
every day, and if the patient becomes very ill, but one attendant
at a time should be in the sick-room.
Bathing. — The typhoid patient should be sponged twice a day,
an ordinary cleansing bath being given. During the bath, it is
not necessary to uncover the patient. Parts of the body may be
bathed and dried, when other parts may be given attention.
Mouth Toilet. — Careful mouth toilet should be observed in typhoid
TYPHOID FEVER 457
fever in children. Gingivitis and ulcerative stomatitis with sec-
ondary cervical lymph-node involvement are not infrequent com-
plications of these cases.
Care of the Discharges. — The discharges from both bladder
and intestine should be received in vessels containing a i : looo
solution of bichlorid of mercury. Carbolic acid should not be used.
The necessity for the attendants to wash their hands with soap
and water after attending to the patient should be made very
plain. They should also be advised as to the proper disposal of
the discharges. In children of tender age who still require the
napkin, it is best to dispense with the usual article and use cheese-
cloth instead, several thicknesses of which may be made of the
required shape and burned when soiled.
The Feeding of Typhoid Fever Cases. — Contrary to the general
practice, I give little or no milk in typhoid cases. Karly in my
professional work I gave milk, which I had been taught was the
only diet for the typhoid patient. I soon discovered that the less
milk was given, the less the tympanites. I found that without
milk the temperature ran lower, that there was less tendencv to
delirium, that the duration of the case was shorter and, as a whole,
less severe.
The diet which I now use consists largely of gruels made from
cracked wheat, barley, rice, oatmeal, or any of the uncooked cereals
by boiling for three hours one ounce of the cereal in one pint of water.
At the completion of the boiUng, boiled water is added to make
the quantity of the gruel one pint. If the gruel is too thick for
drinking, boiled water may be added. The gruel thus prepared is
used as a "stock." It may be given plain, with salt or with sugar
or both. I frequently add, as flavoring, two or three ounces of
chicken or mutton broth. From six to eight ounces of the gruel are
given every three hours — five to six feedings in the twenty-four
hours. The patient is encouraged to drink water, which is given
between feedings. Lemonade, tea, and weak coffee may also be
given between the feedings. In the event of abdominal distention
under the carbohydrate diet, the gruel is dextrinized by the addi-
tion of "Cereo," one teaspoonful to a pint of gruel. The gruel should
be at a temperature of about 140° F. when the Cereo is added.
When the temperature shows a tendency toward a lower level in
or at the end of the third week, zwieback and toast are added to the
diet. Later, when the tongue becomes clear and the breath loses
its characteristic odor, kumyss, matzoon, skimmed milk, scraped rare
beef, and soft-boiled eggs are allowed. With the use of the more
substantial foods, the number of feedings in the twenty-four hours
is reduced to four.
Milk should not be given in any considerable amount before the
temperature has been normal for one week. Even then, in a case
which has had no milk or has had pronounced elevation of tempera-
458 INFECTIOUS FEVERS
ture and intestinal disturbance, the giving of milk may cause a rise
in the temperature. In not a few cases in which the temperature
was running a low course — from ioo° to 102° F. — without tympanites
or delirium, I have seen it shoot up to 105. 5° F., with furred tongue
and distended abdomen, as a result of the administration of milk,
which was usually given at the solicitation of friends, who feared the
patient was being starved !
Illustrative Case. — A few years ago a girl, twelve years of age,
had typhoid fever. The temperature was not high, the range being
from 101° to 103° F. In fact, fever and an enlarged spleen were the
only signs of the disease, until the diagnosis was confirmed by a
positive Widal reaction. The tongue was moist throughout, as is not
unusual when milk is not given. The family were fearful that
the patient was not being sufficiently nourished. The mother
had been told by a physician, a family friend, that such was the
case. She begged that I allow the girl one glass, eight ounces,
of full milk daily. I immediately ordered the nurse to give the
patient one glass of Walker-Gordon milk once in twenty-four hours.
She did so, and in three hours after the first glass the temperature
had risen to 106° F., with abdominal pain and distention. One
bottle of the citrate of magnesia and a high enema were given, after
which the disease resumed its usual course on the previous diet,
without milk, the temperature not going above 99° F. after the
seventeenth day. An uneventful convalescence followed.
Drugs. — With the so-called intestinal antiseptics in typhoid fever,
my experience has been most unsatisfactory, so far as concerns their
influence upon the disease. If there is constipation, the citrate of
magnesia, from four to six ounces, given cold, is grateful to the
patient and usually answers the purpose well. If the bowels do
not move once in twenty-four hours, a high enema should be given.
The digestive capacity is indicated by the condition of the tongue
and may be improved by the use of dilute hydrochloric acid and
the tincture of nux vomica. The following will be suitable for a
child from five to ten years of age:
I^. Tincturse nucis vomicae gtt. xlviij
Acidi hydrochlorici diluti gtt. cxx
Glycerini o iss
Aquae destillatae q. s. adgiv
M. Sig. — One teaspoonful after each meal.
There may be as many as four bowel passages in twenty-four
hours without harm to the patient. In fact, I consider from two
to four necessary to maintain free drainage. When there are more
than six in twenty-four hours, loose and watery in character, the
loss of fluids sustained may be a serious factor in the case, in caus-
ing a concentration of the blood, with a corresponding concentration
of the poison, as shown in the marked general toxemia.
TYPHOID FEVER 459
Diarrhea in typhoid is best controlled by the use of opium com-
bined with bismuth. For a child from three to five years of age,
the following may be given :
I^. Pulveris Doveri gr. x
Bismuthi subnitratis gr. c
(Squibb)
M. Div. et ft. chart. No. x.
Sig. — One every three hours until the stools diminish in frequency,
when they may be given at intervals of from six to twelve
hours.
. In children from one to three years old, the dose of the Dover's
powder should be reduced one-half, the full amount of the bismuth
being given. The amount required to keep the diarrhea under
control will soon be learned. Of course, constipation must not be
produced. If a free bowel action is interfered with, there will be
increased prostration and higher temperature.
Control of the Fever. — A temperature at or below 104° F. is not
interfered with, in the great majority of cases. Of course, a very
delicate child with a weakened heart action may require the use
of antipyretic measures before this temperature is reached. This
necessity, however, is unusual. My observation is that when above
104° F. the patient does better if proper means are used to control
the temperature.
Antipyretic Drugs. — Antipyretic drugs are rarely given. Quinin
in my cases has never proved to be of the slightest value, even
when given in large doses — fifteen or twenty grains in twenty-four
hours — to a child five years of age. The coal-tar products, such
as phenacetin, may be used in small doses without harm, if hydro-
therapy is not applicable, as in a case which I recently saw in a
remote country district. The patient was a boy six years of age.
He was delirious at times, with almost constant tossing about the
bed, sleeping but little, with a temperature ranging from 105° to
106° F. The disease was in the latter part of the second week and
the patient was becoming rapidly exhausted. The parents, densely
ignorant, refused to allow the bath or pack. The sponging, which
was carried out indifferently, had not the slightest effect on the
temperature and appeared to excite the patient. It was suggested
to the attending physician that he give two grains of phenacetin
and one-half grain of the citrate of caffein at intervals of from three
to six hours. It was found that from four to six powders daily were
required to keep the fever within the desired bounds and the skin
moist. They had also a decidedly quieting effect upon the patient,
whose heart action was in no way unfavorably influenced and who
made a complete recovery. Had the great restlessness, the loss
of sleep, and the delirium continued, I have no doubt but that
there would have been a fatal termination.
While there is much truth in what has been written as to the
46o INFECTIOUS FEVERS
depressing effects of the coal-tar products, and while the dangers
from their excessive use are realized, there are occasions where they
are a necessity, and I cannot help feeling that the dangers have
been exaggerated. Probably the diseases in which their use is most
dangerous are pneumonia and the inflammatory conditions of the
heart.
Hydrotherapy. — Pyrexia is best controlled by hydrotherapy.
Sponging with lukewarm or cool water may be tried, and if the case
is not a severe one, this may answer. The child may be sponged
with water at from 70° to 80° F. for one-half hour out of every
two or three hours. Sponging, however, even if it controls the
temperature, may not be the best means of using water for this
purpose, for the reason that many children object to it, and in con-
sequence the sponging disturbs them, increasing their irritability
and reducing their vitality. The use of the bath for the reduction
of fever in children I have discontinued. They invariably object
to it, the bath excites or frightens them, and, as a rule, particularly
in the very young and delicate, the reaction following it is poor.
Moreover, the bath necessitates a great deal of handling, undressing
and dressing, and therefore tires the patient. Reduction of the
temperature by means of a rectal irrigation with cool water has its
advocates. If the temperature is running high and intestinal
lavage is indicated for reasons other than the temperature, it may
be used here, the water being of a lower temperature than that of
the body, though I never use it lower than 80° F. for this purpose.
Without a high body-temperature, however, and other indications
as well, it is never to be used. It causes straining, excites the child,
and thus increases the danger of hemorrhage and perforation.
Furthermore, it is a very indifferent antipyretic, even when used
with water as cold as 75° F. By far the best means of reducing
the temperature in children is the use of the cool pack (page 481).
Its advantages are that it causes no fright or shock, the child being
disturbed comparatively little by it. He may be placed in a towel,
which has been w^et with water at 95° F., and the only manipulation
necessary is to turn him from side to side, so that the towel may
be kept constantly wet with the cool water at the desired temperature.
The pack more effectually controls the temperature than does either
sponging or the tub-bath, and it is thus kept within the desired
hmits. As suggested elsewhere (see page 272), the child should be
removed from the pack when his temperature reaches 102° F.
Heart Stimulants. — If the heart by the rapidity of its action shows
signs of failure, the tincture of strophanthus is our best remedy.
When there is irregularity in force and rhythm, strychnin should be
used. A child from five to ten years of age may be given two drops
of the tincture of strophanthus at intervals of from two to four hours.
Strychnin, y^-q grain at intervals of from three to four hours, may be
ERYSIPELAS 461
given for the same age. Alcohol should not be given as a heart
stimulant until other means have failed. It is a drug to be used
only in conditions of great stress. Its function is to carry us over
and out of difficult places, and it may be given in the form of
whisky or brandy, one to three drams at intervals of from two to
four hours in children from three' to ten years of age. Its con-
tinued administration for a considerable period is not to be ad-
vised. In any disease it is difficult to lay down definite rules for the
administration of heart stimulants. They are used with the hope
of producing a definite effect, and when such effects are produced, a
larger quantity should not be given. It is best always to begin
with small doses and gradually increase until the desired results are
apparent.
Hemorrhage and Perforation. — Hemorrhage has not occurred
in any of my cases which were given the non-milk diet. Should it
occur, the cold coil or the ice-bag should be applied and Dover's
powder given in full doses to control peristalsis. In case of per-
foration, operative procedures are to be resorted to, but these hold
out little hope. Children bear abdominal operations badly, and,
considering the exhausted condition of a young child in the third
or fourth week of a severe typhoid, the outlook is most unfavorable.
ERYSIPELAS
Erysipelas is a particularly fatal disease in infants. In the
new-born, 95 percent of the cases are fatal. Fifty percent of my
cases occurring in children under one year of age have been fatal.
When the streptococcus of erysipelas gains entrance into the skin
of an infant, it is unusual if the entire skin surface does not become
involved before the process subsides. The long-continued high
temperature, the toxemia, the discomfort from the inflammation,
and the interference with nutrition greatly reduce the patient, and
if he resists the disease during the acute stage he is very apt to die
later from exhaustion. This was the outcome in four cases seen
within the past three months at The New York Infant Asylum,
where each child went through the active period of the disease,
but died a week or two afterward from exhaustion and marasmus.
Treatment. — The treatment is unsatisfactory, particularly so in
young children — the younger the child, the graver the prognosis — and
absolutely nothing is to be promised. I have employed scarifications
in advance of the line of the slowly creeping inflammation, and
whether solutions of the bichlorid of mercury, carbolic acid, or
ichthyol were used as a dressing, I have seen the red line pass the
scarified disinfected surface regardless of the nature of the antiseptic
and regardless of the vigor and vitality of the child. The termination
of the cases, whether in recovery or death, depends to a great extent
upon the resistance of the patient and the severity of the infection,
462 INFECTIOUS FEVERS
SO that our first step should be to place the child in the best position
to resist the disease.
Hygiene. — One of the first, perhaps the most important factor
in the treatment of these cases is abundance of fresh air. In
the winter the child does best when placed in a room with windows
wide open, not for a few moments but continuously. Protected with
hot-water bags and sufficient clothing, there is no danger, as long
as the temperature of the room does not fall below 55° F. At
other seasons of the year the patients should, if possible, be kept
out of doors.
Infants with erysipelas are particularly liable to develop gastro-
enteric disorders. In case the child is bottle-fed, the milk mixture
should at once be reduced from 50 to 75 percent by the addition of
barley-water or Granum-water, No. i , so that the amount of fluid
given at a feeding remains unchanged.
Internal medication such as I have used has been of no value aside
from its stimulating or sustaining nature. The tincture of the muriate
of iron is not to be given young infants with erysipelas. It almost
invariably disturbs the appetite and interferes with the digestion.
Local Applications. — The local measure which is unquestionably
of some value is the use of ichthyol. I prefer a 10 percent solution,
if the involved area is one or more of the extremities or a small por-
tion of the trunk. Solutions as dressings should not be used in infants
when the erysipelatous process involves the face or much of the
trunk. When these parts are involved, a dressing of 30 percent
ichthyol ointment in vaselin is applied on strips of lint or linen and
renewed everv three hours. The frequent renewal is important, and
the ointment dressing should be used only on the acutely involved
areas. When in a given case the inflammation begins to subside, the
dressings should be removed and the parts bathed freely. It must
be remembered in this connection that the skin is an important organ
of excretion, particularly of carbon dioxid. The constant covering
of comparatively large surfaces on a small child, interfering, as it
does, with the function of the skin, may become a serious matter.
The local treatment with ichthyol should follow up the extension
of the inflammatory process and be continued until it subsides.
Stimulants. — Nearly every infant with erysipelas will require stim-
ulation. For this purpose small doses of whisky well diluted appear
to answer best. From five to fifteen drops at two-hour intervals for
children under two years of age have aided me, I am sure, in carry-
ing the patient through to a successful convalescence.
Erysipelas is the only disease in which it is wise to use alcohol as
an early and oftentimes the only stimulant. When the inflammation
subsides the child is by no means to be regarded as well. In the
absence of sequelae, such as a phlegmon, an endocarditis, or nephritis,
the vitality may have become so reduced that sudden death may
RHEUMATISM 463
take place when it is thought that the patient is well on the road
to recovery, such a result being due, perhaps, to an unrecognized
myocarditis. During the entire attack, and throughout convales-
cence, the child should be fed to the limit of his digestive capacity,
never beyond it. This can be done only by careful observation of the
case and frequent inspection of the stools.
In the event of high temperature, above 104° F., the cool pack
(page 481) may be effectively used.
RHEUMATISM
Rheumatism is an exceedingly rare disease in children under
two years of age. It is occasionally seen in those between the
second and fourth years and is of very frequent occurrence after
the fourth year.
The manifestations of rheumatism in children are many. Prob-
ably its most frequent manifestation is in the catarrhal inflamma-
tory conditions of the respiratory tract and in indefinite muscle
pains, commonly known as growing pains. Inflammatory conditions
of the upper respiratory tract, particularly such as relate to the
mucous membrane of the throat and the tonsils, in a majority
of instances are due, probably, to a rheumatic infection.
In children, involvement of the joints is also a result of rheumatic
infection, but there is less tendency to joint involvement in them
than in adults.
During the past twelve months I have had four cases of pleurisy
with effusion of rheumatic origin. The rheumatic state or habit,
whatever it may be called, is treated by physicians generally with
entirely too little concern.
Endocarditis is a frequent manifestation of rheumatism — a
part of the disease and not a complication. Some of my most
severe cases of endocarditis have shown the most trivial joint and
muscle symptoms. In other cases there has been endocarditis
without a single joint or muscle symptom. Usually those children
of rheumatic inheritance whom we question closely, we shall find
have had more than their share of tonsillitis and sore throat. It
is the strong tendency to heart involvement in rheumatic children
that should mark any child so affected as an object for special
prophylactic care.
Children with growing pains or with respiratory indications
of rheumatism, such as repeated bronchitis and asthma, with or
without a pronounced rheumatic history, should receive prompt
treatment for the condition. For although we beheve the acute
inflammatory involvement of the heart and joints to be of bacterial
origin, nevertheless, before infection takes place, there must be
a favorable field for the development of the specific bacteria, if there
are such, to operate in. The peculiar condition of the blood and
464 INFECTIOUS FEVERS
tissues, that something which favors a fertile field for the specific
bacteria, may be the result of heredity or of errors in living, particu-
larly as relates to the diet. In any event, proper feeding and appro-
priate dietetic regulation will change this receptive state to one of
apparent health. This is proved by the relief furnished to children
who have suffered much from growing pains, and by a reduction of
from 60 to 80 percent in the number of attacks during the year of
inflammatory throat conditions.
It will usually be found that rheumatic children combine one
or two, or perhaps all, of the following conditions: They have a
rheumatic inheritance, they habitually indulge to excess in sweets —
by which I mean sugar in any form — and a considerable part of
their daily food is red meat.
Treatment. — Diei. — My first step in the management of a case of
this nature is to eliminate red meat from the diet for ten days or
two weeks. A minimum amount of sugar is given, just enough to
make the food palatable. In a case which resists treatment, or when
there is a rheumatic inheritance, saccharin is substituted for sugar.
The child is encouraged to eat freely of green vegetables. The use
of potatoes boiled with the skins on is encouraged. Fish, eggs,
and poultry are allowed as usual. In order that the child may
not suffer from the removal of a large amount of proteid from the
diet, cereals and legumes rich in proteid are given. Particularly
useful in this condition is plain oatmeal, which, of course, should
be cooked three hours. Dried peas, beans, and lentils are given
in the form of a puree.
Drugs. — In addition to these changes in the diet, a child of
from five to ten years of age is given ten grains of bicarbonate of
soda, three hours after breakfast and dinner for one week, and
five grains three hours after each meal for the second week,
after which time he is given five grains of the bicarbonate of soda
twice daily for five days, with a ten-day intermission, when the
dosage is repeated. For six weeks the soda is used in this way— for
five days with ten days' intermission. The low sugar and the low
meat diet should be continued indefinitely if there is a rheumatic
history, or if the child has had repeated rheumatic attacks, whether
such manifestations have been in the throat, in the muscles, or in
the joints. The mother should be instructed to resume the bicar-
bonate of soda with the first complaint of pain on the part of the
child. If the growing pains continue in spite of the diet and the
bicarbonate of soda, five grains of the salicylate of soda should be
given after each meal, the use of the bicarbonate being continued.
It is not wise to continue the salicylate after the acute symptoms
have subsided.
Children who are subject to frequent attacks of rhinitis, tonsilHtis,
and angina, with or without a rheumatic history, should indulge
RHEUMATISM 465
Sparingly in red meat, never more than once a day, better every
second day. Only sufficient sugar to make the food palatable should
be allowed. The use of candy should be reserved for very rare
occasions. A warm bath should be given at night, followed by a
generous friction of the skin in drying.
Illustrative Case. — Asthmatic bronchitis is usually dependent
upon the rheumatic state. Repeated attacks suggest the possibility
of their being of rheumatic origin. A Httle girl eight years old was
brought to my office about a year ago, because of repeated attacks
of bronchitis. The mother, a woman of unusual education and
refinement, stated that the child had had an average of two attacks
of bronchitis monthly during the previous year, and at least pne
every month since she was five years of age. On my expressing
some doubt as to the frequency, she stoutly maintained that her
statement was correct. The family lived in Brooklyn and had been
told that the child could not remain there during any portion of the
year. She had spent the colder months at different winter resorts,
with very little, if any, resultant effect upon the severity or fre-
quency of the attacks. The child was pale and inclined to stoutness.
There had been no other illness of consequence. The attacks were
peculiar in that they were of short duration but very severe. There
usually was a temperature range from 100° to 101° F. There were
cough and difficulty in breathing with occasional attacks of marked
air hunger. The attacks were always accompanied by severe
coryza. She came to me at the end of an attack. An examination
of the chest showed throughout a fairly even distribution of mucous
rales, involving the smaller tubes. Aside from the bronchitis and
secondary anemia, the examination was negative. The child had
attended school at irregular intervals, but only for a few weeks
of her Hfe. While getting the history, I asked, as a matter of routine,
if the child snored or if she were a mouth-breather. This caused
the mother to remark that the child had been under the care of
throat specialists at different times and each of them had removed
a set of tonsils and a set of adenoids ! She did not think that there
was very much left. In spite of a normal rhinopharynx, the colds
had continued. There was not a sign of a tonsil and the nasopharynx
was free. In taking the family history, I had learned that it was
rheumatic on both sides, extending back for two or three generations.
The mother claimed to have suffered a great deal from rheumatism.
In getting the personal history, I asked if the child was fond of red
meat. The reply was that she lived on it, and cared for little else,
unless it was sugar. Here was a girl eight years of age who would
not drink milk until sugar had been added to it. Cereals, stewed
and raw fruits were loaded down with sugar before she would touch
them.
In my instructions as to the treatment, red meat was allowed
30
466 INFECTIOUS FEVERS
once every second day and sugar was reduced to a minimum — pro-
bably not rnore than one-fifth the usual amount being given. She
was to be bribed, if necessary, to eat green vegetables, cereals, and
fruits. Expectorant and cough mixtures were discontinued. She
was given twenty grains of the bicarbonate of soda and twenty
grains of the salicylate of soda daily for three weeks. Later, the
drug treatment was continued at intervals during the remainder
of the winter. She passed through the following winter without
a sign of rhinitis, bronchitis, or asthma, although she continued to
live in Brooklyn.
Another case somewhat similar was sent to me by a well-known
rhinologist. The girl, seven years old, had suffered from repeated
attacks of bronchitis and asthma. She had been confined to her
home a greater part of each winter. Her general condition was
thoroughly wretched. Her family physician attributed the con-
dition to enlarged tonsils and adenoids. The child was sent to
New York for operation. The operation was performed and the
child returned to her home. As a result the patient could breathe
easier and sleep better, and suffered much less during her attacks
of asthmatic bronchitis; but the frequency of the attacks was in
no wav affected. Early the following summer, they returned to
the rhinologist, who, finding the condition of the upper respiratory
tract satisfactory, asked me to take charge of the case, remarking
that he had "cut everything in sight and out of sight" ! The child,
as did the other referred to, proved to be an excessive meat and
sugar eater, and, moreover, the mother's family was rheumatic.
The treatment outlined above was instituted ; and, while the results
were not so flattering, the condition was much improved; only
three attacks occurred during the next twelve months, and the child
gained fifteen pounds in weight.
Repeated inflammatory involvement of the mucous membrane
of the upper respiratory tract in children, in the absence of enlarged
tonsils and adenoids, suggests strongly a rheumatic element as a
prominent causative factor. Rheumatic pleurisy requires the
same treatment as rheumatism. In my four cases referred to above
there was a rheumatic history in two. The children were between
two and six years of age. There was no pneumonia, no lung in-
volvement of any nature. Aspiration showed clear fluid, which,
upon examination, proved sterile. The children were given an
anti-rheumatic diet with the salicylate and the bicarbonate of soda
in doses suitable for their ages, with the result that in all there was
a complete absorption of the fluid in less than one w^eek. The
treatment of rheumatic endocarditis will be found elsewhere (page
291).
Treatment. — Diet. — Acute articular rheumatism or rheumatic
fever is rarely seen in children under three years of age. It is usually
RHEUMATISM 467
the larger joints that are involved — the shoulder, the elbow, the knee,
or the ankle. The lesion may be single or multiple. Rest in bed is
an absolute necessity. The diet of the patient may consist of milk,
junket, gruel, toast, stale bread, weak tea, stewed fruit, and orange-
juice, Vichy and lemonade may be given to drink. There should
be one evacuation of the bowels daily.
Local Measures. — Considerable comfort may be furnished by
local measures, which will permit the child to sleep, resulting in
a much improved food capacity. The affected joint or joints
should be comfortably supported on a cushion or pillow, and
the parts kept well protected by cotton-wool or flannel dressings.
The U. S. P. lead and opium solution which is used to moisten the
gauze dressings will aid in relieving the pain. The joint is loosely
wrapped in strips of linen which have been wet with the warm
solution. Over this is placed oiled silk to prevent rapid evaporation
and over all a flannel bandage is wrapped. In the acute cases the
dressing should be changed every hour until the pain is relieved.
This can readily be done without disturbing the patient. A liniment
composed of menthol, two drams, tincture of opium, one and one-
half ounces, and enough alcohol to make six ounces, applied on
strips of linen and covered with oiled silk, is another form of local
treatment which has been of considerable service in relieving pain.
The dressing should be renewed every two or three hours if the
case requires it.
Drugs. — \^arious drugs, such as oil of wintergreen, aspirin, and
combinations of the alkalies with the salicylates, have been used
in a considerable number of cases. The most effective internal
medication has been the bicarbonate in association with the sali-
cylate of soda. The salicylate must be given in large doses. Two
points, however, are to be kept in mind in the use of large doses
of salicylate in children: Their depressing effect upon the heart,
and their tendency to produce derangement of digestion, as evi-
denced by nausea and vomiting. The salicylate should never be
given with the stomach empty. It is given to the best advantage
after meals, and always in solution. For a child five years of age,
the following may be prescribed :
I^. Sodii salicylatis 5ij
Elixiris simplicis glss
Aquae q. s. ad giv
Sig. — One teaspoonful four times daily after meals, in plain water
or in Vichy.
There are about twenty-four teaspoonfuls in a four-ounce bottle.
The average teaspoonful, as is well known, holds more than one
dram. Computing twenty-four doses to a four-ounce mixture, we
give this five-year-old patient twenty grains of salicylate of soda
in twenty-four hours. The amount may be increased to thirty
468 INFECTIOUS FEVERS
grains if the condition is serious. Larger doses than thirty grains
to children of this age I do not consider safe, as I have seen such
doses followed by irregularity of the heart's action and cyanosis.
The average child from eight to ten years of age will take thirty
grains daily without inconvenience. From the second to the third
year, I have given from twelve to fifteen grains repeatedly, with
most satisfactory results. The bicarbonate of soda may be given
in combination with the salicylate, but it is best given alone in
Vichy or carbonic water between meals. For a child five years
old or under, twenty grains should be given in twenty-four hours.
In children from seven to ten years of age, thirty to forty grains
daily is the amount required. During an attack of rheumatic
fever, the patient's heart should be examined daily. The dosage
both of the salicylate and the bicarbonate of soda should gradu-
ally be reduced, as the condition of the child improves.
It is my custom never, willingly, to let a child who has once had
an attack of acute articular rheumatism disappear from my observa-
tion. With repeated attacks, endocarditis is liable to develop sooner
or later. After one attack, the parents are advised as to the proba-
bility of a recurrence, and its dangers are pointed out to them. They
are instructed to keep the child on a low meat-and-sugar diet-^red
meat never being allowed oftener than once every second day, while
sugar is given only in sufhcient quantity to make the food palatable.
Five days out of every fifteen, ten grains of the salicylate of soda,
separately or combined with ten grains of the bicarbonate, are given
daily. This should be continued for six months, when the five-
day treatment out of each month will suffice. In some cases I
have continued this method indefinitely.
At the present time a boy eleven years old, who has had two
attacks of rheumatic endocarditis, is taking ten grains of each of the
above drugs daily for one week out of each month, and has been
doing so for two years. He comes of a long line of rheumatic an-
cestry, and so prominent is the rheumatic element in him, that he
frequently has attacks of angina and muscle pain in spite of the diet
and the above prophylactic treatment.
PELIOSIS RHEUMATICA
In this unusual affection, which appears to be of rheumatic
origin, purpura is a prominent symptom. In my patients the pur-
puric area has always been over the anterior portion of the lower
extremities. ]\Iy cases, five in number, have all occurred in those
who had had previous attacks of rheumatism or chorea, or in those
in whom the rheumatic clement was prominent, as shown by re-
current tonsillitis or recurrent bronchitis. A further proof of the
rheumatic origin of the disease is the fact that the cases usually
yield readily to treatment for rheumatism.
TUIJIiRCULOUS PERITONITIS 469
In one of my patients there were two distinct attacks, both of
which yielded fairly well to the salicylate of soda and the iodid of
potash. The medication and diet are the same as that suggested
for rheumatism. In case erythema nodosum is present at the same
time, local measures for the relief of pain (page 409) will be neces-
sary.
ACUTE GENERAL PERITONITIS
This disease is not an infrequent one in young children. I
have seen four cases during the past year. Two were associated
with scarlet fever and two with enterocolitis. Perforation of the
intestine and trauma may cause peritonitis, as in the adult. The
most frequent cause, however, is the invasion of the peritoneum
by pathogenic bacteria. The peritoneum in young children appears
to be particularly susceptible to various forms of infection. Three
symptoms were present in my cases — persistent vomiting, abdominal
distention, and constipation. Pain was absent in one case and
not marked in some of the others. The pulse in all was small and
rapid. The constipation was as obstinate as though actual ob-
struction existed.
The medical treatment in my experience has been without value.
Every case has resulted fatally. In the majority, surgeons were
called in consultation, but invariably advised against operative pro-
cedures.
Never having had a case recover, I am not in a position to advise
treatment.
TUBERCULOUS PERITONITIS
In tuberculous involvement of the peritoneum the disease is
usually well advanced by the time it comes into the hands of the
pediatrist. The chief question that concerns us at the present time
is as to the advisabiUty of the operation of laparotomy.
When to Operate. — My course is as follows: If there is marked
ascites with much discomfort, operation is advised at once. It
would seem that early operation furnishes the best chance for re-
covery in the actively acute cases. When there is evidence of in-
terference with normal peristalsis, as indicated bv persistent consti-
pation and visible peristalsis, it means that intestinal obstruction is
imminent, and immediate laparotomy is advised. When the above
conditions do not obtain, I have found it advisable to postpone ope-
ration and attempt to relieve the patient by hygienic measures, diet,
and medication.
Some of the cases seen by me were absolutely hopeless at the
time, showing marked tuberculous processes elsewhere, and there-
fore were not considered fit subjects for operation. In the non-
surgical treatment of these cases the chief points of importance
to be considered are nutrition, fresh air, and a thorough daily bowel
evacuation.
470 INFECTIOUS FEVERS
As long as there is a temperature above ioo° F. or abdominal
pain, the patient should be kept in a recumbent position and out
of doors. Moderate exercise is to be encouraged as soon as the
conditions allow. The same methods of constitutional treatment
as to diet and cHmate are to be followed out as are laid down in the
treatment of Pulmonary Tuberculosis (page 285). The patient
should be weighed once a week, and in case of a continuous loss
in weight and strength extending over five or six weeks, with or
without fever, in spite of the advantage of diet and climate, oper-
ation is advised, regardless of the stage of the process, provided
always there is no active tuberculous process elsewhere. When
the weight remains stationary or nearly so for two or three months,
laparotomv is advised. In the event of improvement and gain
in w^eight, the expectant treatment is continued.
Illustrative Case. — The necessity for operation cannot always be
convincingly impressed upon the parents. A few years ago the con-
dition of a private case, a boy three years of age, was persistently
bad. There was moderate fever, emaciation to a marked degree,
with later, tubercular involvement of two of the dorsal vertebrae.
Laparotomy was suggested early in the illness, but it was refused,
and the child after a prolonged illness made a complete recovery
both from the tuberculous peritonitis and the tuberculous caries
of the vertebrae. In this case I am convinced that an unnecessary
risk was taken, and that recovery from the peritonitis would have
been much more rapid and the vertebral involvement probably
prevented by an early laparotomy.
DACTYLITIS
Dactylitis consists of a fusiform sweUing on one or more of the
phalanges of the fingers. It may be of two forms, dactylitis syphi-
litica and dactylitis tubercidosa. The differentiation between the
two conditions is oftentimes most difficult. In the syphiUtic type
the lesions are more apt to be multiple and are associated with
syphilitic lesions elsewhere. Furthermore, these cases are favorably
influenced by anti-syphiHtic treatment, which is not the case with
the tuberculous form.
Aside from the anti-syphilitic treatment, the management of
the two forms is the same. Absolute rest to the parts appears to
be essential for successful treatment. This is best secured by the
use of splints, which must be kept bound on the fingers for months
in such a way as effectually to immobilize them. In a recent case
of the tuberculous form, successfully treated in this way, the fin-
ger was kept in splints for six months. When abscess and necrosis
occur, the case must be treated along surgical lines, the immobility
of the parts being maintained as completely as the conditions allow.
GLANDULAR FEVER 47^
TUBERCULOUS BONE DISEASE
Children afllictc-d with tuberculous bone disease, whether in the
spine, the hip-joint, the knee-joint, or elsewhere, 'should be in the
hands of the general or orthopedic surgeon. The constitutional
treatment of these cases, however, is most important, and is largely
along nutritional and hygienic lines, for the better the nutrition
and the physical condition of the patient, the more complete and
prompt will be the results of the surgeon's efforts.
Diet. — A tuberculous child should receive a generous amount of
fat and nitrogenous food. There should be no forced feeding, as this
almost invariably makes the child ill, or he will become disgusted with
all food. What is required is a liberal supply of properly selected,
properly prepared food. The diet advocated in the Tardy Malnu-
trition cases and in Pulmonary Tuberculosis should be employed
here. The five meals a day which are often advocated for tuberculous
children, I have been unable to give with advantage. The most fre-
quent feedings that I have been able to give with benefit for children
of three years or over are the three daily meals, with a glass of milk
or cocoa in the middle of the afternoon. As much outdoor hfe
as is possible should be afforded the patient. City children always
improve more rapidly when placed in good surroundings in the
country.
GLANDULAR FEVER
Glandular fever is usually seen in children after the first year.
The disease is due to a local infection the nature of which is unknown.
The lymph-nodes at the angle of the jaw are involved, forming
an elongated tumor between the angle of the jaw and the sterno-
mastoid which may reach a considerable size. I have seen cases
during the past winter in which the tumors were as large as hens'
eggs. Both sides are usually involved; the swelling is first noticed
on one side, which is often followed by an enlargement of the glands
on the opposite side.
The symptoms are fever, usually from ioi° to 104° F., prostra-
tion, and loss of appetite. The disease is to be differentiated from
mumps in that the parotid glands are not involved, and from acute
simple adenitis by the absence of throat involvement. In several of
the cases seen during the past winter and spring (igo6), the rhino-
pharynx was normal.
The treatment consists in the continuous use of ice-bags and
laxatives, such as milk of magnesia or citrate of magnesia, sufficient
to produce one or two evacuations daily, a reduced diet of broths
and gruels, and keeping the patient in bed. The swelling may last
from five days to two weeks, and in my cases has subsided without
suppuration.
472 INFECTIOUS FEVERS
CYCLIC VOMITING
Recurrent attacks of persistent vomiting are frequently seen
by the pediatrist. An attack comes on suddenly with little or
no warning. At first the contents of the stomach are vomited;
later, in many cases, whatever may be taken in the line of food or
drink. When no food is taken, the dry retching and vomiting of
mucus continue, the latter for a few hours, for an entire day, or
for several days. The most prolonged case under my observation
was in a boy three years of age, who vomited persistently for thir-
teen days. The cessation of the vomiting is usually as abrupt as
its onset, the patient asking for and retaining the nourishment
which is given him. If the attack is a short one and mild in char-
acter, the customary diet will usually be taken at once thereafter
without inconvenience. If the attack has been prolonged, with
much straining and vomiting of mucus streaked with blood, or
if there has been a decided hematemesis, which I have seen in some
cases, the resumption of the feeding will necessitate considerable
care. In such cases broths, kumyss, and bland non-irritating articles
of diet generally will have to be given.
Treatment. — According to my observation direct medication to the
stomach during the attack is valueless. Our efforts are best exerted
in maintaining the nutrition of the patient. All attempts at supply-
ing water or food by the stomach should be discontinued. Nutrient
enemata and colon flushings are invaluable in all of the prolonged
cases — those lasting over forty-eight hours. In addition to the
discomfort produced by the vomiting, these patients suffer greatly
from thirst. The necessary amount of fluid can be supplied by colon
flushings. For a child five years of age one pint of normal salt solution
may be introduced into the colon through an ordinary rectal tube
(page 208). I have often known patients to retain as much as
two pints of fluid a day when it was thus given. If the case promises
to last more than three days, it is best to begin with nutrient enemata
on the third or fourth day. For this purpose I employ from six
to eight ounces of completely peptonized skimmed milk, to which
the whites of two eggs have been added. This is given at eight-
hour intervals. The use of the salt solution and peptonized milk
furnishes sufficient fluid nutriment to sustain the child until the
vomiting ceases. In two cases only have I been obliged to resort
to morphin hvpodermatically, to control the frequency and violence
of the vomiting attacks.
All of my cases of cyclic vomiting — and I have treated over
thirty of them — have been without exception in children of rheu-
matic inheritance or in those in whom rheumatism was evident
by some unmistakable sign. It is therefore of great advantage
to consider these cases and treat them as though thev were of rheu-
CYCLIC VOMITING 473
matic origin. The attacks perhaps may not be entirely prevented,
but in practically every case they may be delayed by putting the
patient upon suitable treatment in the intervals. My custom is
to give only a hmited amount of animal proteid and a diet scanty
in sugar or with sugar entirely excluded if the case is a severe one.
The use of green vegetables, fruits, and cereals is encouraged.
To a child of from three to ten years of age, from nine to twelve
grains of salicylate of soda or aspirin are given after meals daily
in divided doses, for five days out of every fifteen. During the
ten days of rest from the salicylate, five grains of bicarbonate of
soda are given twice daily between meals. This scheme of treatment
is continued for months. If the salicylate of soda interferes with
digestion or with the appetite, aspirin in equal dosage is substituted.
By following this method of treatment in cases where attacks had
been occurring every month or six weeks, the intervals between them
have been increased to six months or a year, and in several instances
the attacks have entirely ceased. Spasmodic treatment of these cases
is of little value; only persistent treatment is effective, and there
must be confidence and cooperation on the part of the family or
anv treatment will fail.
TEMPERATURE IN CHILDREN
Normal Temperature. — The question is often asked: What is
the normal temperature of a baby or young child of a given age?
In order to answer this question from our own observation, a study
of the matter was carried out at my suggestion by Dr. H. G. Myers,
resident physician at The New York Infant Asylum. This study
comprises fifty-nine cases, the ages varying from birth to one year.
Only well children were selected for the observation, the majority
being breast-fed. The temperatures in each instance were taken
by the rectum for four minutes.
It was found in these infants that the birth temperature ranged
from 96° to 98° F., exceeding 98° F. in but five cases, when it was
between 98° and 99° F. In one it was 94° F. During the twenty-
four hours following birth there was a rise in the temperature usually
of about one degree. From this time on, there was little varia-
tion in the temperature, when the child was well, regardless of the
age. There would be a variation at different times of the day of
a fraction of a degree, it being higher in the evening. Upon looking
over the charts upon which the results were chronicled, one is im-
pressed by the uniformity of the temperature, ranging, as it does,
within fairly narrow limits, from 98° to 99.2° F.
Instances when the temperature arose to 99.5° F. were occasionally
seen, but 100° F. was very unusual. It is not claimed that the tempera-
ture of a well child may not reach 100° F. ; in fact, there were occa-
sions when it rose to 101° F. and illness could not be proved, arid
had not the temperature been taken for the purpose above men-
tioned, no elevation would have been suspected, for when next taken
the temperature was normal. In those cases in which a rise was
proved to be an early sign of illness, the recording of the tempera-
ture was discontinued and the first reading was not included in the
observations. In one child a temperature of 103° F. was found. It
remained at this point for three hours, when it fell to normal with-
out any other manifestation of trouble. When, however, the ther-
mometer registered over 99.5° F., some cause for the elevation could
usually be discovered; though it may have been nothing more
than excitement or a slight indigestion.
Several years ago I personally made a similar series of observa-
tions at the Country Branch of The New York Infant Asylum in
twenty-five healthy children under eighteen months of age. The
temperatures were taken four times a day, the observations extending
over an entire week. It was found in these well children that the
474
TEMPERATURE IN CHILDREN 475
temperature varied from 98° to 99° F. ; when it rose every day above
99.5° F., some abnormal condition was always found to explain it.
Judging from these observations in seventy-four well children,
ranging in age from birth to eighteen months, whose temperatures
were taken several hundred times, it would seem that a daily rise
above 99.5°, F. may be considered abnormal. An occasional rise,
however, considerably higher than this, as above mentioned, may
occur and does occur in perfectly healthy children, without being
of any special significance.
Fever.— By fever, then, in infants and children we understand an
increase above that which is considered the normal body-temperature.
In children, for cHnical purposes, the rectal temperature should
always be taken. For those under five years of age the mouth is
unsafe, because the child is apt to bite off the thermometer bulb,
and unrehable, because the lips will not remain closed the requisite
three or four minutes. The axillary temperature is thoroughly
misleading and should never be depended upon. Thermometers
should be carefully disinfected with alcohol after using. One-
minute thermometers, according to my observations, are often
unrehable and should not be used.
The highest temperature personally known to the writer was
111° F. This was as high as the thermometer could register. It
occurred in a child of ten months who was in a convulsion, which
was one of the first symptoms of a tuberculous meningitis. The
child had been placed by the parents in water at a temperature of
115° F. It had been in the water about ten minutes before the
rectal temperature was taken. How much the temperature was due
to the illness and how much to the hot water will never be known.
The temperature responded promptly to a cold bath. The child never
regained consciousness and died of meningitis ten days after the
initial convulsion.
Fever may or may not be an index of the gravity of a disease;
thus we frequently have a temperature ranging from 103° to 105°
F. in tonsillitis, acute indigestion, and stomatitis — ailments w^hich
respond very quickly to treatment and which present no serious
aspects. In typhoid fever, pneumonia, scarlet fever, and diph-
theria, however, when the temperature range is above 104° F., it
is a symptom of considerable value, as indicating the severity of
the infection; so that it is not the fever itself, but the condition
back of and associated with it, which makes it a sign of clinical
value. In pneumonia, children bear a comparatively high tem-
perature, 104° F., for example, without much discomfort or danger;
while in the acute intestinal disorders of summer, an equal degree
of fever is borne very badly, and if continued is of grave signifi-
cance. This must be kept in mind in our dealings with fever.
When is a given temperature to be interfered with? is a ques-
476 TEMPERATURE IN CHILDREN
tion which concerns all practitioners. This depends to a great
extent upon the cause of the fever and its effects upon the patient.
If the fever produces diminished assimilation, loss of sleep, irri-
tabiUty, and restlessness, it will do the child harm by diminishing
the normal resistance to disease, and should be relieved whether
it is 102° F. or 105° F., so that interference is dependent not so much
upon the height of the temperature as upon its effects upon the
patient.
The methods of reUeving fever are: (i) Elimination: This ap-
plies particularly to the gastro-enteric tract and the skin. In a
majority of the cases of high fever due to an acute indigestion with
resulting toxemia, a purgation, a bowel-washing, and a carefully
adjusted diet for a day or two, and the case is well. We remove
the cause of a fever, and the fever subsides. Unfortunately, this
means of controlling fever is limited to the gastro-enteric tract.
(2) Diaphoresis, by which is understood the production of an exces-
sive perspiration, will also relieve high temperature. The most
reliable way of bringing this about in a child is by the use of mod-
erately heavy covering and the administration of the tincture of
aconite, in doses of one-half to one drop every hour, — eight doses
in twenty-four hours; or Hquor ammonii acetatis, two drams every
two hours, for a child one year old. (3) By far the most satisfactory
means of controlling fever depends upon the local abstraction of
heat by means of sponging (page 480), tub-baths (page 30), and
cool packs (page 481). (4) Antipyretic drugs: Much which borders
on the sensational has been written about the harmfulness of an-
tipyretic drugs, particularly the coal-tar products. Used in
large and frequent doses, they certainly may do a great deal of
damage; under certain conditions, used in small doses and repeated
at intervals of from three to six hours, they may be and often are
of benefit. Aconite and the liquor ammonii acetatis are of some
value, as above stated, but they are of little value in controlling
a very high persistent temperature. The coal-tar products furnish
the best antipyretic drugs and may be used with safet}^ but should
be used only when, for any reason, the local abstraction of heat
by the application of cold is impossible. In many families there is
too Httle intelligence to make a cold pack either possible or safe.
In severe cases of pneumonia and scarlet fever, and in the intestinal
diseases, sponging often will not answer. Only a trained nurse
or a very intelligent mother should be entrusted with a pack. More-
over, sponging and tub-bathing, if repeated too frequently, particu-
larly during the night, exhaust the child. Spongings or tub-baths
are often strenuously objected to by parents as well as by the patient,
and if the nurse is one of the family, her sympathy will counter-
balance her judgment, and the result be far from satisfactory.
Under such conditions, when the application of cold to the skin
OBSCURE ELEVATIONS OF TEMPERATURE 477
is impossible, a combination of phenacetin and caffcin, alone or
with Dover's powder, has proved effective. The antipyretic treat-
ment of scarlet fever is the same as that of pneumonia or typhoid
fever.
My use of antipyretic drugs has been confined almost entirely
to the ignorant in private work, and to dispensary patients. For a
child of one year or under, one grain of phenacetin with one-fourth
grain of citrate of caffein may be given and repeated at three-hour
intervals if the temperature requires it. For a child two years of age
i^ grain of phenacetin and ^ grain of citrate of caffein at three-hour
intervals; three years and over, i^ to 2 J grains of phenacetin with ^
to I grain of citrate of caffein, at intervals of from three to six hours.
If there is much restlessness and irritability which is not thus con-
trolled, Dover's powder may be added — ^ grain to each dose,
for a child of from three to six months of age; ^ grain between
six and twelve months; one grain after the age of two years is
reached. It is always wise to caution parents as to the use of Dover's
powder in children. They should be told that if the child beocmes
"heavy," or difficult to arouse, the powders must be discontinued.
That phenacetin and citrate of caffein cannot be given in solution is
unfortunate. I^ike all insoluble powders, they are best given in
some mucilaginous mixture, such as barley-water or one of the
cereal jellies. Fruit- juice or apple-sauce usually answers well.
Antipyrin, for the reason that it forms a tasteless mixture with
water, succeeds better with some intractable children, and may be
used in the same doses as phenacetin; although as an antipyretic
it is less efficient.
OBSCURE ELEVATIONS OF TEMPERATURE
Perhaps the most annoying cases in pediatric work are those
with an elevation of the temperature for which no adequate cause
can be discovered. In the section on Normal Temperature cer-
tain possible variations are given which I regard as within the
limits of health. When these boundaries are passed, when there
is a temperature range between 99° and 101° or 102° F., or a tem-
perature persistently at 100° or 101° F. without any apparent cause,
and continuing for days and weeks, the medical adviser is not in
an enviable situation. Such cases coming to the pediatrist through
consultation or otherwise are sometimes easy of solution. At
other times, however, the cause of the fever may never be discovered,
and the patient eventually gets well, leaving us still in ignorance of
the cause of the fever.
Active Exercise in Nervous Children. — This is not infrequently
the cause of an elevation of the temperature. I have seen several
cases of this nature. A few years ago I saw in consultation a country
child three years of age, whose temperature every afternoon at one
478 TEMPERATURE IN CHILDREN
o'clock was 1 02° F. The child, while not vigorous, showed no
signs of illness. He ate well, slept well, and played hard. There
was a slow gain in weight. The fever was discovered by the mother,
who thought that the child, who was a blonde, looked flushed every
day at about the same time. The temperature by rectum was nor-
mal in the morning and normal at night. This condition, to the
attending physician's knowledge, had persisted for six weeks before
I saw the patient. How long there had been a daily elevation of
the temperature above the normal before the mother discovered
it, we have no means of knowing. The doctor, an excellent prac-
titioner, had suspected, examined the child for, and treated him
for various diseases; the first being malaria, with no response to
quinin; then typhoid fever, as by suggestion and constant inquiry
the child came to imagine that he must be sick, and complained
of languor. The fever continued, however, beyond the usual time
allowance for typhoid fever and there were no other symptoms.
There was no enlargement of the spleen and the blood had been
repeatedly found negative to the Widal reaction. Other possible
causes of the fever were also given attention. One day the doctor
suggested tuberculosis. This aroused the family and friends
and a consultation was the immediate result. In company with
the doctor, I saw the child at its home. I found a rather thin
blond boy, three years old. The family history was excellent.
There was one other child, six years of age, who was well and a
good specimen of robust boyhood. The patient had never had a
pulmonary disorder and no disease of the respiratory tract other
than slight bronchitis. There was no apparent association of the
condition with any intestinal or infectious disease. An exhaustive
physical examination failed to reveal any abnormaUty other than
a small umbilical hernia and a slight enlargement of the inguinal
and submaxillary glands. The blood was not examined. The
child was pale and doubtless a blood examination would have
revealed a mild secondary anemia. The appetite was fairly good;
the bowels were reported regular and his stools normal. The child
had not been kept in bed, as the family did not consider him very
ill. The physical examination being negative, I questioned the
mother very closely as to the child's habits of life. I found that
he rose at 7 a. m., had breakfast at 7.30, played with his big brother
and two older boys until one o'clock, when he had dinner. A glass
of milk and a piece of bread and butter were given as a luncheon
at II A. M. I found that he played very actively, kept up with the
older boys, and was unhappy when he was not with them. At-
tempts had been made without success to entertain him with less
strenuous play. It was at midday, sometimes before, sometimes
after dinner, that the temperature reached the highest point. It
seemed to me that here, probably, was a case of fatigue temperature.
OBSCURE ELKVATIONS OF TEMPERATURE 479
I accordingly suggested that the boy be undressed and put to bed
at 1 1. 1 5 A. M. after the Hght luncheon and be made to rest and
sleep if possible. At 1.15 he was to be taken up for dinner, his
temperature first being taken. These instructions were faithfully
carried out, and I am pleased to state that this ended the daily
rise in temperature. The case was one of an active, nervous child
becoming overtired in his attempts to hold his own with older and
stronger boys. The patient improved rapidly in his physical con-
dition and is now, after an interval of three years, perfectly well.
Another child, four years of age, was seen in consultation with
a New York physician, because of a daily elevation of the temper-
ature to from 100° to 102.5° F-. which had continued for six weeks.
The child was thriving and otherwise perfectly well. No cause
of the fever could be discovered in his physical condition. He
had a noisy, excitable nurse, who was inclined to exciting games
and rough play with the boy. With a dismissal of the nurse the
fever ceased.
Otitis. — Persistent fever, following the acute catarrhal affec-
tions of the upper respiratory tract and the exanthemata, is
sometimes explained by a suppurative process in the middle ear,
without other symptoms than the fever.
Encysted Empyema. — A small area of encysted empyema may
explain a persistent fever, following pneumonia. Holt describes a
most interesting case of this nature in which there was for over
four weeks a temperature range from 100° to 105° F. Autopsy
showed a small collection of pus between the diaphragm and the
lung.
Periodic Fever. — Not infrequently we see cases which show
some of the clinical signs of malaria as regards periodicity in the
temperature, but without splenic enlargement, or the presence
of the malarial organism in the blood. Yet, often, these cases quickly
respond to full doses of the bisulphate of quinin.
Typhoid Fever. — Occasionally a case with low persistent tem-
perature elevation, obscure for a week or two, proves to be a mild
typhoid.
Tuberculosis. — An elevation of the temperature is sometimes
the first premonitory symptom of tuberculosis. Tuberculosis in
a child, however, is usually an active process when it involves the
lungs, and can readily be made out. When other parts are involved,
such as the bones, glands, skin, or peritoneum, the manifestations
are usually sufficiently plain to indicate the condition.
Intestinal Infection. — Intestinal infection of a latent type may
be the cause of persistent fever. In a suspected case in the
absence of bowel symptoms, it is well to give a laxative and put
the child temporarily on a reduced diet consisting largely of carbo-
hydrates.
480 TEMPERATURE IN CHILDREN
Unexplained Elevations of Temperature. — I have known children
to run an unexplained temperature of from 100° to 101.5° F. for
weeks, without any other sign of illness. I have had these cases
examined by eminent consultants and I have seen them recover
without a diagnosis. Of one thing, however, we may rest assured:
If a competent, thorough examination of the patient does not reveal
the cause of the temperature, we are safe in concluding that there
is nothing of a very serious nature back of it.
Illustrative Case. — The history of a case of this kind, which gave
me no end of trouble and annoyance, may not be without interest.
The patient, an eight-year-old boy, was the only son of a habit-
ually anxious mother, who had unfortunately learned to use the
clinical thermometer. She took her boy's temperature after school
one day early in December. She found that the thermometer
registered 100.5° F. I was consulted, saw the boy in the evening,
took his temperature, by mouth, with my own thermometer, and
found it 100.8° F., with no other evidence of disease. He was per-
fectly normal in every other respect. He maintained that he felt
well, did . not need a doctor, and wished to be let alone to study
his lessons. The following morning the temperature was 100° F. ;
in the evening it was nearly 101° F. For six weeks this temperature
range continued, never below 100° F., never higher than 101.2° F.
The boy, against my advice, was taken from school. He was put
to bed, and a half-dozen consultants saw him without shedding
any light on the case. Finally the mother became reconciled to
"doing nothing " for her son, and he was taken to a nearby winter
resort. I suggested to the father that before leaving town he should
"accidentally" drop the thermometer on the hardwood floor and
then refuse to have another in the house. This he managed to do,
straightway. The boy had an excellent time at the winter resort,
played with his sled in the snow, skated on the lake, fell through
the ice once and received a thorough wetting, without harm. In
three weeks he returned, improved as much as any city child improves
from a country outing. His temperature was not taken during these
three weeks at the winter resort and has not been taken since, except
where there were evidences of illness. He is now developing along
normal lines and is a fair physical specimen for his age.
COLD SPONGING IN FEVER
Sponging with plain water, with salt water (a teaspoonful of
salt to a pint of water), or with alcohol and water (one-fourth alcohol
to three-fourths water) is a means of reducing high temperature
with which every physician should be familiar. Cool sponging,
75° F. to 80° F., plain or medicated, is useful for two purposes:
as a sedative and for the reduction of fever. In measles or scarlet
fever, although the temperature may not be high, the itching and
THE COOL PACK 48 1
burning of the skin prevent sleep, and the patient is very uncom-
fortable, but often, under such conditions, he will fall asleep during
a careful sponging. In pneumonia, in typhoid fever, and in the
intestinal disorders of summer, my nurses have a standing order
to give a cold sponging for fifteen minutes at any time when, in their
judgment, it may be indicated, not on account of the fever but
because of its sedative effect upon the patient. A sponging of from
ten to fifteen minutes three or four times a day with cool water,
65° to 75° F., will greatly help a baby, whether sick or well, to pass
successfully through the hot days of summer.
Sponging for fever, while possessing less antipyretic value than
do other measures, such as a cold pack, for example, has the advan-
tage in that it is safe and easy of application in the hands of the
most unskilled, and will be of assistance in controlling high tem-
perature when other means are not available. In order not to antag-
onize or frighten timid children, it is often wise to begin with the
water, whether plain or medicated, at 95° F. and reduce the temper-
ature gradually by the addition of cold water or small pieces of ice.
It is rarely necessary to go below 60° F., and usually the sponging
should not be continued longer than thirty minutes. It is well
to have an interval of rest — from thirty to ninety minutes — between
the spongings, as too frequent sponging, if resisted, may exhaust
the patient. Every part of the body should be sponged in turn,
but it is not necessary to expose the patient, who should be covered
with a flannel blanket. When the process is completed the skin
should be briskly rubbed for a few minutes with a dry, rough towel.
THE COOL PACK
The cool pack properly applied is without the slightest danger
to the patient and is the best means we possess with which to com-
bat a continued high fever. It may be used as freely and with
as much success in the exanthemata as in typhoid fever or pneu-
monia. That cool water may not safely be applied to the skin of
a child with scarlet fever or measles is a fallacy which it is our duty
to explain to mothers.
The pack is prepared as follows, a rubber sheet being used to
protect the bed-sheet: A large bath towel or some thick, soft, absorb-
ent material should be used; muslin, linen, or any thin material does
not answer as well. Slits are cut in the towel large enough for the
arms to pass through and the towel is folded around the body,
enveloping only the trunk and buttocks (Fig. 54). The pack should
not extend below the middle of the thighs. This leaves the arms
and the greater part of the lower extremities free. A hot-water
bag, carefully guarded, should be placed at the feet and the patient
covered with a blanket of medium weight. The towel is moistened
with water at 95° F. This higher temperature is necessary at first
31
482 TEMPERATURE IN CHILDREN
in order not to frighten the patient, as sudden cold is apt to do,
and also to avoid shock. In two or three minutes the towel, without
being removed, is again moistened with water at 90° F., later with
water at 85° 1'., and still later at 80° F. When the temperature
of the water reaches 80° F., it is better to hold it at this point
for half an hour, when the patient's temperature should again be
taken. If at the beginning his temperature was 105° F. and now
shows but slight or no reduction, the temperature of the water
with which the towel is moistened should be reduced to 70° F., or
if necessary, even to 60° F. The child throughout need not be
disturbed, except to turn him from side to side to wet the towel
with water of the desired temperature, this being one of the advan-
tages of the pack over a tub-bath or sponging.
For the first hour or two in a pack the temperature of the pa-
tient should be taken every half hour. When it is reduced to 102°
F., the pack should be removed, for. if it is continued longer, too
great a reduction may take place. If it rises again rapidly to 105°
F. or higher, it is well to keep the patient in the pack continuously.
The degree of cold necessary, in the individual case, to keep the tem'-
perature within safe limits will soon be learned. I recently kept in
a pack for seventy-two hours a boy four years old, with a lobar
pneumonia. In this case a continuous pack of 70° F. was required
to keep the temperature at 104° F. or slightly lower. The towel,
or other material employed, should not be used for more than six
hours, when it should be changed for a fresh one.
Another reason for frequently taking the temperature is that
early in the attack we do not know how it will be affected by the
continued cool applications. In some children it is very readily
influenced, and in such a case collapse might follow a very sudden
reduction of the temperature. In cases readily controlled, the pack
may be necessary for only one-half hour or an hour, at intervals
of three or four hours. An ice-bag may with advantage be kept
BATHING THE SICK 483
at the head when the child is in the pack. Suddenly enveloping
the entire skin surface in a cold sheet at 70° F., as advocated by
some writers, may increase the temperature and produce grave
symptoms of impending death because of the sudden contraction
of the superficial blood-vessels, which sends the blood to the vis-
cera, producing congestion of the internal organs.
BATHING THE SICK
There is a pronounced objection among many to bathing children
when ill, particularly when they are suffering from respiratory
diseases or from the exanthemata. The functions of the skin as an
organ of excretion and elimination are most important, and it is
absolutely necessary that, during illness, when oftentimes the
metabolic processes of the body are being carried on to an exces-
sive degree, all the eliminating organs be kept in the best pos-
sible condition in order that they may the better do their work.
Therefore to have the skin perform its functions properly it must
receive proper attention, and there is no better means for stimu-
lating it to a sharp reaction than bathing with weak salt water
— a teaspoonful of salt to a gallon of water — at a temperature
of 85° to 90° F., followed by a brisk rubbing. It is the sudden
contact of cold air with the moist skin, which occurs sometimes
in undressing a child, without the attendant reaction, that
causes the shock, the "cold," which is usually attributed to the
bath. It is the temperature of the room in which the child is un-
dressed, the careless method of bathing, and not the apphcation of
water which causes the trouble. But even the danger of this ex-
posure is greatly overestimated. In order to avoid every possible
danger, however, the temperature of the room in which the sick or
deUcate child is bathed should be raised to 80° F. I have yet to
know of a child who suffered from the effects of a bath, properly
given.
VACCINATION
Every infant in fair health should be vaccinated. The vaccina-
tion should be done as soon as the child is thriving on a rational diet.
The younger the child at the time of vaccination, the less the consti-
tutional disturbance. In well infants, vaccination should never be
delayed beyond the fifth month.
The Site. — The site selected for the vaccination is usually on the
left arm in boys, at about the point of insertion of the deltoid, and in
girls on the outer aspect of the calf of the leg. I have found, how-
ever, that it is a matter of much more convenience to the mother in
dressing and handling the child, if the leg is selected in both sexes.
The dressing is more easily appHed to the wound and can the more
readily be kept in place on the leg. Further, in the manipulation
necessary in dressing and undressing, much less discomfort is occa-
sioned when the sore is on the leg.
The Method. — Before scarification of the skin, the site selected
should be well scrubbed with common soap and water, dried, and
then washed with alcohol. The area of scarification should not
be over one-quarter of an inch in diameter, and should be suffi-
cient to produce only a light flow of serum. A deep scarification,
producing a free flow of blood, is very apt to be unsuccessful. The
best scarifier is an ordinary sewing-needle, which should be sterilized
by placing the point for a few seconds in an alcohol flame. The
virus which is furnished in hermetically sealed capillary glass tubes
is the safest to use. The drop of virus is deposited on the abraded
surface and rubbed well into the wound, using the side of the needle
for this purpose. When the wound is thoroughly dried, a protective
dressing should be appHed. The safest and most convenient is a
sterile gauze bandage, which is wrapped several times around the
arm or leg and secured with a safety-pin. On account of the shape
and position of the parts, the bandage is very apt to become displaced,
downward. In order to prevent this, a strip of adhesive plaster one
inch wide and five or six inches long is placed over the bandage at
right angles to it. The middle portion of the plaster readily adheres
to the bandage and the two ends, at least two inches long, are an-
chored to the skin.
The After-treatment. — The mother is instructed to report in seven
days after the vaccination. On the seventh day the dressing is re-
moved, and if the vaccination is successful, the characteristic pearl-
like vesicle will be present. If, on account of accident or rubbing of
the parts by the patient, the vesicle is broken, the non-adhering
484
VACCINATION
485
gauze should be carefully cut away around the sore, allowing that
which adheres to remain. Under no conditions should the wound
be opened. A gauze dressing is again appHed and kept in position
by adhesive strips. At the end of the exudative stage, usually about
five or six days, the dressing should again be changed, either by
the mother or the physician, and continued until the crust falls,
which will be from the third to the fourth week after the vaccina-
tion.
If there is no sign of the vesicle in ten or twelve days, the vaccin-
ation, if primary, should be repeated. Re- vaccination should be
practised at least once in five years and at more frequent intervals
during epidemics of smallpox.
If vaccination is properly performed, the dangers attending it are
practically nil. That death and serious results have followed vaccin-
ation is no argument against its use, but is a grave reflection on the
manner in which, as a rule, it is performed. The scarification of
bacteria-laden skin, producing at the outset an open wound which is
indifferently or not at all protected from further infection, is very apt
to produce complications of a troublesome and often serious nature.
Erysipelas, extensive cellulitis, and sloughing of the parts as the re-
sult of careless vaccination are not infrequently seen at out-patient
departments for children. I have seen in two cases a reinoculation,
as the result of scratching the sore, thus transferring the virus in one
case to the upper lip and in the other to the left upper eyelid, these
places being the site of the vaccination sore.
There is not a vaccination shield, which I am familiar with, on the
market that is safe for use. Some cause a maceration of the wound,
others allow a free entrance of bacteria, while still others prevent a
free superficial circulation of the blood and increase the chance of
ulceration. Moreover, the shields are very apt to become displaced,
causing a rupture of the vesicle, with resulting infection.
A certain degree of constitutional disturbance is present in every
child in which the vaccination is successful. After the first month,
however, the younger the child the less the constitutional disturbance.
Children vaccinated during the second or third month suffer practi-
cally no inconvenience. There is a rise in temperature, from 100*^
to 101° F., for a day or two, and when the process is at its height, per-
haps a slight degree of restlessness. Time and again I have seen
children, vaccinated at this age, pass through the various stages
without manifesting the slightest discomfort. In older children the
severity of the constitutional symptoms appears to increase with the
age. Thus, a child in the second or third year may have fever, 102°
to 104° F., loss of appetite, coated tongue, and moderate prostration.
Very active symptoms rarely last longer than three days unless there
is a considerable accompanying cellulitis.
Active treatment other than relieving the immediate constitu-
486 VACCINATION
tional symptoms is rarely required. Even when there is an active
cellulitis I have found it advisable not to attempt local applica-
tions, such as lotions or compresses. Ointments all have a tendency
to dissolve and loosen the crust, producing an open wound. When,
on account of suppuration, the crust falls, leaving a deep ulcer
formed by granulation tissue, active local treatment will be required.
Such ulcers are often seen in out-patient work. A wet dressing of a
saturated solution of boric acid has answered well in these cases. If
the wet dressing cannot be kept properly applied, a lo percent oint-
ment of boric acid may be applied twice a day and will be found of
considerable servdce in hastening the closure of the wound. The
ointment should be smeared freely on gauze or clean linen and held
in position by a properly applied bandage. In young children the
ulcers are often most obstinate. In a few instances I have known
them to continue from eight to ten weeks. In a case in which the
healing is particularly slow, the familiar dressing of balsam of Peru,
5 percent, in castor oil, applied twice daily on a pad of several thick-
nesses of gauze and covered with oiled silk, has appeared to hasten
the granulation. Unhealthy granulations may have to be curetted
before the dressing is applied.
INSTRUCTIONS FOR THE SUMMER
In addition to advising parents as to a selection of a summer re-
sort for the family, I advise the mother as to the particular care of
the child during the summer whether he is to remain in town or go
to the country. During the months preceding the heated term
every mother whose infant is under my care, whether in dispensary
or private, is made aware of the dangers of the next few months,
and means are suggested and written directions are given as to how
to pass through the summer with the greatest security. She is
told what market milks are the best. She is told that the milk
must be kept on ice, with ice surrounding the bottle, from the time
of its delivery until it is given to the child, except, of course, the
time spent in its special preparation.
During the hot months in New York city the child's digestive
capacity is not equal to that of the colder months. Children who
remain in the city are given weaker milk mixtures by a reduction of
from 15 to 25 percent in the fat and proteid, the sugar remaining
the same. True, the infant may not gain very much in weight, but
on a reduced diet he is much more apt to pass through the summer
without intestinal disorders, and there is an abundant opportunity
for him to gain later on. Mothers are instructed as to the amount
of clothing required. They are told that a napkin, a mushn slip, a
loose-mesh knitted band, are all that are required, on very hot days.
They are instructed to give the infant frequent drinks of boiled
water between his feedings, and if he suffers much from the heat, as
shown by prickly heat and restlessness, to give him two or three
spongings daily with a cool solution of bicarbonate of soda, one tea-
spoonful to a pint of water.
It is made very plain to them that vomiting or a green undigested
stool is a danger-signal which always means that the milk must be
withheld for twenty-four hours or longer whether the child is nursed
or bottle-fed, and that either barley-water or one of the other carbo-
hydrate gruels (page 119) must be substituted until such time as
the stools improve or the vomiting ceases. This is one of the most
important life-saving measures the physician can teach the mother.
An immense majority of the intestinal diseases of summer which
destroy thousands of lives yearly, have their origin in a neglected
acute indigestion and diarrhea, which if properly managed means a
slight illness of but a day or two. Therefore it is further impressed
upon the mothers that upon resuming the milk diet, it must be given
at first greatly reduced in strength and then gradually increased
487
488 INSTRUCTIONS FOR THE SUMMER
until food of the previous strength is given. Beginning with one-half
ounce of skimmed milk in each feeding, by watching its effects upon
the temperature and the stools, an increase of perhaps one-half ounce
may be made each day.
I have experienced not a little trouble in the past in securing safe
milk for infants who were removed at a considerable distance from
the depots of the better class of dairies that supply certified milk.
The average farmer is notoriously careless in the handling of milk,
and in the country districts, where the milk-supply should be the best,
it is often as bad as can well be imagined. In remote country dis-
tricts where the milk is furnished by the farmer a special arrange-
ment is made, by which he agrees that the cow's belly, udders, and
teats shall be wiped off with a damp cloth before milking; that the
milker's hands shall be washed before milking; that the few jets of
the fore-milk shall be thrown away ; and that as soon as the milk is
drawn it shall be strained through absorbent cotton into a quart
milk bottle, suitably corked, and placed in a pail of cracked ice. A
mother of one of my patients is using her silver champagne-cooler
for this purpose at the present time! The cracked ice and the ab-
sorbent cotton are, of course, furnished by the consumer. For the
extra trouble the farmer receives from twelve to twenty cents a
quart for the milk. At one resort three babies were supplied in this
way by one small producer, with a comparatively safe milk. The
improved milk-pail (Figs. 12, 13) insures a much cleaner milk, as it
offers much less opportunity for droppings to fall into it during the
milking.
For those who have country homes and who can control their
milk-supply the above precautions may be carried out to the letter.
By such careful control of the home product, and by the use of milk
from those dairies only which observe the above precautions, the acute
digestive disorders of summer among my patients are rendered a very
unusual occurrence. These precautions, with the knowledge of the
mother or nurse as to what to do at the first sign of a digestive dis-
order, will reduce the number of the so-called summer diarrhea cases
to a very insignificant figure.
Among out-patients in large cities who have to use other milk
and milk less clean, summer diarrhea must prevail. Among these,
however, the death-rate may be remarkably reduced through the
education of the mothers. At the out-patient department at the
Babies' Hospital there is a very low death-rate from summer diar-
rhea. At this dispensary there is a clientele of fairly intelligent
mothers who have been coming to us for years. By pamphlets
of instructions as given below, and by showing these mothers
that we have a personal interest in their children, we gain their con-
fidence. They believe what we tell them, and, as a result, we re-
peatedly have children brought to us well along the road to recovery.
INSTRUCTIONS FOR THE SUMMER 48^
For example, a child had developed diarrhea; he had been given
a dose of castor oil, his milk was stopped and barley-water or rice-
water given. The mothers are further told that it is never a good
thing for a baby to have diarrhea ; that a diarrhea is never without
dangers; and that an infant who has frequent attacks of indigestion
during the cooler months is very sure to develop diarrhea during the
hot months ; and that the safest means of keeping a baby well in the
summer is to keep him well all the year round.
Rules for the
CARE OF DISPENSARY INFANTS AND YOUNG CHILDREN
During the Summer.
1. Clothing: During the very hot days the baby should wear a
napkin, a thin gauze shirt, and a thin muslin slip; an abdominal
binder made of thin material, and loosely applied, maybe worn until
the child is six months of age. After this age the binder is not nec-
essary.
2. Bathing: Every child should have one tub-bath daily. On
very warm days from two to four ten-minute spongings with cool soda
water (one teaspoonful of bicarbonate of soda to a pint of water)
will greatly add to the child's comfort.
3. Fresh Air: Fresh air is of vital importance. Leave the win-
dows open. Keep the child in the open air when possible. Avoid
the sun. Select the shady side of the street and the shade in the
parks.
4. Sleep: Sleep is very necessary for growing children. A noon-
day nap of at least two hours should be insisted upon until the child
is four years of age.
5. Soiled Napkins: Soiled napkins should be placed in some cov-
ered receptacle containing water, and washed at the earliest oppor-
tunity.
6. Drinking-water : Boil one quart of water every morning. Put
it into a clean bottle. Keep the bottle in a cool place. Give the
water between the feedings, as much as the child will take.
7. Breast-feeding: The mother should wash the nipple with plain
cold water before each nursing. She should be very careful as to
diet and the habits of life. The bowels should move once a day.
Constipation in the mother prpduces illness in the child. There
should be three plain, well-cooked meals daily, consisting largely of
milk, meat, vegetables, and cereals. Beer and tea are often harmful.
A large quantity, a couple of pints or more daily of either, is positively
dangerous.
From birth to the third month: The baby should be nursed at two
and one-quarter hour intervals during the day. Nine nursings in
490 INSTRUCTIONS FOR THE SUMMER
twenty-four hours, with only one nursing between 10.30 p. m. and
6 A. M.
Third to sixth month : The nursings should be at three-hour intervals
during the day ; seven to eight nursings in twenty-four hours, with one
night nursing.
Sixth to ninth month: The child now takes a larger quantity at
each feeding and the night nursing is not necessary. He should be
nursed at three to three and one-half hour intervals ; six nursings in
twenty-four hours.
Ninth to twelfth month: The nursings should be at three and one-
half to four-hour intervals, five nursings in twenty-four hours.
8. Bottle-feeding: The bottle should be thoroughly cleansed with
borax and hot water (one teaspoonful of borax to a pint of water)
and boiled before using. The nipple should be turned inside out,
scrubbed with a brush, using hot borax water. The brush should
be used for no other purpose. There should be three or four sets of
bottles and nipples. The bottles and nipples should rest in plain
boiled water until wanted. Never use grocery milk. Use only
bottled milk w^hich is delivered every morning. The milk should be
boiled for five minutes immediately after receiving. The feeding
hours are the same as in breast-feeding. Children of the same age
vary greatly as to the strength and amount of food required. A
mixture, when prepared, should be poured into a covered glass fruit-
jar and kept on the ice. For the average baby the following mix-
tures will be found useful :
For a child under three months of age: Nine ounces of milk, twenty-
seven ounces of boiled water, four teaspoonfuls of granulated sugar.
Feed from two to four ounces at two and one-quarter-hour intervals —
nine feedings in twenty-four hours.
Third to sixth month: Eighteen ounces of milk, thirty ounces of
barley-water, six teaspoonfuls of sugar. Feed four to six ounces at
three-hour intervals — seven feedings in twenty-four hours.
The barley-water is prepared by boiling a tablespoonful of Rob-
inson's barley flour or Cereo Co.'s barley flour in one pint of water for
twenty minutes; strain and add water to make one pint.
Sixth to ninth month: Twenty-four ounces of milk, twenty-four
ounces of barley-water, six teaspoonfuls of granulated sugar. Feed six
to eight ounces at three-hour intervals — six feedings in twenty-four
hours.
Ninth to twelfth month: Thirty-eight ounces of milk, twelve ounces
of barley-water, six teaspoonfuls of granulated sugar. Feed seven to
nine ounces at three and one-half hour intervals — five feedings in
twenty-four hours.
9. Condensed Milk: When the mother cannot afford to buy bot-
tled milk, when she has no ice-chest or cannot afford to buy ice, she
should not attempt cow's-milk feeding, but canned condensed milk
SUMMER RESORTS 49I
may be used as a substitute during the hot months only. The can,
when opened, should be kept in the coolest place in the apartment,
carefully wrapped in clean white paper. The feeding hours are the
same as for fresh cow's milk.
Under three months of age: One-half to one teaspoonful condensed
milk; barley-water No. i (see formulary, page 123), two to four
ounces.
Third to sixth month: Condensed milk, one to two teaspoonfuls;
barley-water, four to six ounces.
Sixth to ninth month: Condensed milk, two to three teaspoonfuls;
barley-water, six to eight ounces.
Ninth to twelfth month: Condensed milk, three teaspoonfuls;
barley-water, eight to nine ounces.
10. Feeding after one year of age: All children should be weaned
at the age of twelve months unless otherwise ordered by a physician.
The bottle-fed, also, at this age require more than milk and cereal
water. During the second year children are almost invariably badly
fed.
Four meals a day should be given at the same hours every day.
The mother will select suitable meals from the following articles:
soft-boiled egg; scraped rare beef; strained broth of beef, mutton,
or chicken with stale bread broken into it; toast and butter; stale
bread and butter; toast and milk; stale bread and milk; oatmeal
(cooked three hours) and milk; hominy (cooked three hours) and
milk; cornmeal (cooked two hours) and milk; farina (cooked one
hour) and milk. The milk used must be boiled, during the hot
weather.
11. Summer Diarrhea: When the baby has loose green passages
it means that he is sick and needs medical attention. The disease is
frequently mild at the beginning. There may be no fever and the
child may show no signs of illness other than the diarrhea. Such a
baby oftentimes, with milk-feeding continued, becomes dangerously,
if not fatally, ill in a very few hours. The simplest cases of vomit-
ing and diarrhea during the summer must never be neglected. A
baby sick in this way should be given two teaspoonfuls of castor oil.
Stop the milk at once. Give only barley-water or rice-water until
the' child can be taken to the family physician or to a dispensary,
SUMMER RESORTS
Where to take a baby for the hot months of the year is a vexed
question which is raised in many citv households every year, and it
is one concerning which the physician is frequently called upon for
advice. Several years of observation of a great many New York city
children who have spent the summer out of town have led me to the
following conclusions :
First, the most desirable summer outing is, the first half of the
492 INSTRUCTIONS FOR THE) SUMMER
season at the seashore, the remainder inland, preferably in the moun-
tains.
Second, the next place in order of desirability is inland, preferably
the mountains, for the entire summer.
Third, the least desirable is the seashore for the entire summer.
It is not to be understood that many children will not do well
if kept at the seashore throughout the hot months. Some, indeed,
improve most satisfactorily, but among my own patients I have re-
peatedly been impressed with the disadvantages of a too prolonged
stay at the seashore. If kept there during August, infants are apt
to show signs of lassitude, and while not ill, they do not return to the
city in the autumn with the vigor, appetite, and general robustness
which characterize those from the hills and mountains. It must be
remembered that only New York city children are referred to. Chil-
dren whose home is a seaport thrive best when given the benefit of
a complete change to the dry, invigorating air inland. Children with
catarrhal tendencies, bronchitis, adenoids, before or following opera-
tion, and children who have had attacks of rheumatism or who show
rheumatic tendencies, should not go to the seashore, wherever their
residence. In referring to an inland resort, the mountains, by which
we understand an elevation of from 1500 to 2000 feet, are not always
necessarv. The place selected, however, should be at an elevation
of at least 600 feet. For cases of chronic bronchitis and rheumatism,
a soil of sand or gravel is best, and the sleeping-room of the child
should always be above the ground floor.
Other points to be considered in connection with the summer
outing are the kitchen facilities, which must be ample. Often the
larger hotels refuse the right of way to the kitchen. I find that in
this respect much more liberty is given in the smaller hotels and
boarding-houses. The proper preparation of the child's food in the
cramped quarters of sleeping-rooms is not impossible, but it is often
difficult and always objectionable; therefore if a cottage is available,
it will be greatly to the child's advantage. Before selecting a home
for the summer, the drainage and the source and quality of its milk-
supply should receive the most careful attention. Country well-
water or spring-water should invariably be boiled before using.
THERAPEUTIC MEASURES
COUNTER-IRRITANTS
The counter-irritants which I have found especially useful in pedi-
atrics are mustard, capsicum, turpentine, camphor, chloroform, and
iodin.
Counter-irritants are useful in children for two purposes — for the
relief of pain and for the effect upon internal inllammation and con-
gestion. Without doubt the diseased conditions in which counter-
irritation is of most value are in the acute affections of the respira-
tory tract, such as bronchitis, bronchopneumonia, and pleurisy. In
acute bronchitis, when the terminal bronchi are involved, when there
is cyanosis and rapid respiration — from sixty to eighty per minute —
enveloping the thorax in a mustard plaster, one part mustard to
two of flour (see page 259), and keeping it in position until the
skin is well reddened, will often reduce the respirations from twenty
to thirty per minute, and the child, previously tossing and restless,
will fall asleep. I have repeatedly been asked by nurses and mothers
if the counter-irritation could not be applied more frequently because
of the apparent relief experienced by the patient. The applications
may often be made with advantage at intervals of from four to six
hours. They should be sufficiently strong to produce the desired red-
ness of the skin in from live to ten minutes. This will usually be
produced by using one part of mustard to two of flour, when the
applications are first used. When the skin becomes tender from
the repeated applications, but one part of mustard to five or six of
the flour may be required. If the plaster is made too weak, it must
remain long in contact with the skin, which thereby becomes macer-
ated.
Indications. — In Acute Inflammations of the Respiratory Tract. —
When the bronchitis is of the asthmatic type, when there is decided
bronchial spasm associated with bronchial catarrh, the counter-
irritation furnishes not a little relief. In this condition the whole
thorax should be enveloped. In bronchopneumonia with consid-
erable bronchitis, local applications of mustard over the involved
areas are to be advised. The pain from pleuritic inflammation oc-
curring independently of or at the onset of lobar pneumonia, or
when it develops during bronchopneumonia, may be considerably
relieved by counter-irritation. Here also the mustard should be
used only over the painful area. When the pain is severe, equal parts
of mustard and flour may be used for the first application, if carefully
494 THERAPEUTIC MEASURES
watched, for a quick, sharp skin reaction should be produced. If
there is any further action than that of a sedative through retarding
the inflammatory process within, we have no means of proving it.
The mother or nurse should always be cautioned to watch the skin
under a counter-irritant so that a bUster shall not be produced.
During the stage of engorgement and congestion of the bronchi,
indicated by roughened or sonorous breathing with occasional sibilant
rales, a brisk counter-irritation with mustard, or with camphorated
oil and turpentine, appears to hasten the progress of the case toward
recovery. That a respiratory disease is ever aborted by these
methods, as claimed by some, is exceedingly doubtful. If the tur-
pentine is used with the camphorated oil, the proportion should be
one part of turpentine to two parts of the camphorated oil. The
mixture should be well shaken before use and applied with the hand
vigorously for ten minutes or until a distinct redness of the skin is
produced. The mustard or the turpentine should be used in these
cases at least three times a day. I know of no condition when it is
necessary to blister a child's skin. Capsicum vaselin may be used
in the same way and for the same purpose as the camphorated oil
and turpentine.
In Colic. — In severe colic a turpentine stupe will often furnish
prompt relief, twenty drops of turpentine being mixed with one pint
of water at io6° F. Into this a piece of flannel is dipped and wrung
sufficiently dry not to moisten the bed-clothing and placed over the
abdomen. Over this is placed a dry flannel and oiled silk so as to
retain the heat and moisture. The application may be renewed
every fifteen or twenty minutes if necessary.
In Pleurisy and Empyema. — When adhesions exist in empyema
and pleurisy, while the pain is not acute, there is an uncomfortable
drawing, dragging sensation in the chest which may persist for
months. This has been relieved in a few of my cases by the tincture
of iodin, U. S. P., painted over the painful parts every third or fourth
night.
In Intercostal Neuralgia. — In intercostal neuralgia, not infre-
quently seen in overworked school-girls, the repeated application at
interv^als of three or four days of tincture of iodin over the point of
exit of the involved nerve, will often be followed by complete cessa-
tion of the pain. For the pain in acute articular rheumatism, chloro-
form liniment, U. S. P., may be applied to the joint.
ANESTHETICS
That the use of anesthetics in children is attended with consider-
able danger is proved by the statistics relating to the subject. That
the greatest care and judgment should be exercised in the selection
of an anesthetic for a child is readily understood. As a routine an-
esthetic for the 3^oung, ether is preferable because of its safety. The
, ANESTHETICS 495
popular belief that chloroform is without danger is an error and not
sustained by statistics. There are conditions, however, when ether
is contraindicated. In cases in which there is bronchial involvement,
ether increases the bronchial secretions and produces a free flow of
saliva, which is hable to be aspirated into the lungs. In case of any
obstruction to respiration, as in laryngeal diphtheria, retropharyngeal
abscess, and enlarged glands which may encroach upon the air-
passages, chloroform and not ether should be employed. Ether is
further contraindicated in scarlet fever or in nephritis. In such
cases chloroform is to be selected. Chloroform is to be used also for
the sake of convenience, if other conditions allow, in operations about
the mouth and the nose. Chloroform is contraindicated in general
weakness, exhaustion, collapse, and in anemia. Ether given by the
drop method should be used in those cases. Statistics of chloroform
anesthesia show a considerable mortality in operations for adenoids
and enlarged tonsils. The interference with respiration and the sud-
den hemorrhage make chloroform dangerous in these operations. In
heart disease with imperfect compensation, any anesthetic is dan-
gerous, but ether by the drop method is the least so. Nitrous oxid
gas, which of late has become very popular, should be used with cau-
tion in children under two years of age. Young children are very
easily asphyxiated by gas; the younger the child, the greater the
danger. Under two years of age, sudden and alarming asph\Tcia
has resulted from its use. It should be used, therefore, very spar-
ingly and the patient watched most carefully for signs of cyanosis.
The use of gas in children usually precedes the administration of
ether, as it renders the use of the latter much easier for the patient.
It is contraindicated, however, in any condition where dyspnea
is present; in fact, in any illness in which respiration is impeded,
gas is dangerous. The combination of gas and ether in such cases
is not as safe as chloroform, which is to be given in a minimum
amount with oxygen as a safeguard.
Danger-signals During Gas Administration :
Cyanosis; jerking respirations; dilated pupils; convulsive
movements of any portion of the body.
Danger-signals with Chloroform :
Pallor; ashen color; feeble, shallow respirations, gasping in
character; dilated pupils and separation of the eyelids;
slow, feeble heart action.
Danger-signals with Ether :
Marked cyanosis; stertorous breathing; rapid pulse; dilated
pupils; short, quick, gasping respiration.
The use of ethyl chlorid is in the experimental stage. Statistics
show quite a mortahty from its use. In case the condition of the
patient shows any of the danger-signals, it should temporarily or
permanently be discontinued and some other form of anesthetic
substituted.
496 THERAPEUTIC MEASURES
COLON FLUSHING
In colon flushings a normal salt solution should invariably be
used. It is given with the idea of having it retained and absorbed
for the purpose of furnishing needed fluid to the body. It may be of
service in any case in which but little fluid is taken by the mouth.
It has been particularly serviceable in severe cases of scarlet fever,
diphtheria, pneumonia, and cyclic vomiting, when little fluid was
taken, or if taken, was not retained. The large amount of fluid
which the colon will absorb when the organism demands it is sur-
prising.
In a case of cyclic vomiting, a boy, who had retained absolutely
nothing given by mouth for three days, retained one pint at the
first colon flushing, one-half pint more after six hours, and a sec-
ond half -pint six hours later. The flushings were begun on the third
day of the attack. Although the prostration was extreme, the
prompt improvement in the general condition of this patient was
most gratifying. After the first injection the pulse improved, the
apathy disappeared, the child began to ask questions and showed
interest in his surroundings.
Severe toxic cases of diphtheria and scarlet fever, where but little
fluid is taken and where the toxicity of the blood is extreme, as
shown by the stupor and delirium, are often much improved by the
free use of colon flushing, which supplies the water which the child
needs but which cannot be given by mouth, or if given may not be
retained.
A boy nine years of age, ill with scarlet fever, who could take
very little fluid, was able to retain eight ounces of a salt solution
given at eight-hour intervals for three days.
A child six months of age had retained absolutely nothing on the
stomach for six days, because of intussusception. When I saw him
on the sixth day, the respiration was superficial and slow. He was
cold and practically pulseless. The second heart-sound could be
heard but faintly with the stethoscope. The intussusception, greatly
to my surprise, was reduced by water-pressure (page 212). Hot
salt-water flushings were at once begun; the patient retained ten
ounces, given at a temperature of 1 10° F., and in a few minutes there
was a very perceptible improvement. With repeated flushings at
six-hour intervals the child continued to improve, and made a perfect
recovery.
I usually order the salt solution given in quantities of from one-
half pint to a pint, depending upon the age of the child, at mtervals
of from six to eight hours, but never at a lower temperature than
100° F.
The apparatus required is a small rectal tube attached to a foun-
tain syringe. The flushing is best given with the patient resting on
AIvCOHOL 497
his left side with the buttocks elevated on a pillow, the tube, well
oiled, being introduced at least nine inches into the bowel. The
solution is allowed to pass into the bowel, when the tube is quickly
withdrawn. To assist in the retention of the fluid, the patient
should remain on his side for one-half hour.
ALCOHOL
In its relation to children, alcohol, regardless of the form in which
it is used, must always be considered as a drug and not as a beverage.
It is occasionally of great service in diseases of children. Under
certain conditions it answers better than any other means of stimu-
lation we possess. The fact that it is grossly misused does not in any
way detract from its value in illness. It is too often given, chiefly
for the reason that its use, in the form of whisky and brandy and
wine, is advocated in medical works in many of the ordinary ail-
ments of childhood where really it is absolutely contraindicated.
Its use, in my hands, has been that of a food and stimulant in
very grave conditions, the duration of its usefulness being often
completed in a day or two. When given to children for a
prolonged period even in moderate quantities, it invariably inter-
feres with digestion and assimilation, and therefore does harm.
It is very liable also to act as an additional irritant to the kidneys,
which are prone to show inflammatory changes as a result of the
systemic toxemia, due to the disease. We have heart stimulants
which are ordinarily as effective as alcohol and without its danger
either to the stomach or the kidneys.
It is my practice never to give alcohol early in an illness, unless
the onset is accompanied by profound prostration, but rather to
hold it in reserve until absolutely necessary. Used in this way, it
has been of much service in two conditions in which, in my opinion,
nothing can replace it. I refer, first, to that time which may arise
in any grave disease when the heart fails to respond to the usual
stimulation, as in the crisis of lobar pneumonia, and in the profound
toxemia of scarlet fever or diphtheria. At these times the powers
of assimilation for most drugs as well as for food are reduced to a
minimum. When food is rejected or taken badly, when the useful-
ness of strychnin, strophanthus, musk, camphor, and digitalis has
been exhausted, then give alcohol, and give it in as large doses as
may be required to produce the desired results. It is astonishing
what large quantities of alcohol may be given without the slightest
intoxicating effects in many such conditions. When given well
diluted it is usually well borne and assimilated, it supports the heart,
improves the respiration and often will carry the patient through
to a successful convalescence even when the outlook is very un-
promising. As the system readily becomes accustomed to alcohol,
it must be given in increasing doses. If it is begun early in the ill-
32
498 THERAPEUTIC MEASURES
ness, it will have lost its stimulating effects by the time it is most
needed. Brandy or whisky, well diluted, is the form in which it is
generally used.
The second condition in which alcohol is useful is in cases with
greatly lowered vitality resulting from some severe illness, such as
typhoid fever, enterocohtis, or pneumonia. With a child suffering
from shock bordering on collapse, or when in collapse with a sub-
normal temperature with all the vital powers at a low ebb, alcohol
will do much to sustain him. In such cases whisky, well diluted —
I part whisky to 6 of water — given at intervals of two or three hours,
will hasten recovery. If the child cannot swallow, the whisky may
be given by gavage; if vomited, double the quantity, well diluted,
may be given by the rectum. Its hypodermic use is infrequently
resorted to chiefly for the reason that other remedies, such as strych-
nin and digitalis, are more effective than alcohol when so given.
The doses vary from five drops to one-half dram every one or two
hours, twelve to twenty-four doses in twenty-four hours, for a
child one year of age. A child two years of age may be given one
dram at intervals of one or two hours. Its use is attended with the
least disturbance when it is given after the feedings.
HEAT AS A THERAPEUTIC AGENT
Heat has long been used as a therapeutic measure. In infants
and children it has a wide range of usefulness, either as dry heat or
by the use of water as a vehicle.
Moist Heat. — Heat, water-borne, is used as follows:
In colic and indigestion and as a diuretic, internally.
In acute gastritis, as a sedative, by sipping it.
In convulsions, idiopathic and uremic, by means of baths.
In convulsions, idiopathic and uremic, as colon flushings, 105°
to iio°F.
In colic, as a hot stupe applied to the abdomen.
In torticollis, as a hot compress to the neck.
In sprains, as a hot compress to the joint or muscle.
In acute ariicidar rheumatism, as a hot compress to the joint.
In retention of the urine, as a hot compress applied to the lower
abdomen and bladder.
In suppression of the urine {acute nephritis), as a poultice or hot
compress over the kidneys and in colon flushings, 105° to 110° F.
In cerebrospinal meningitis, as a hot bath or hot compress to the
trunk and lower extremities.
In pleurisy, as a hot compress to the painful area.
In acute angina, as a gargle.
In conjunctivitis, as a hot compress.
To hasten suppuration in an abscess, as a poultice or compress.
COLD AS A TllERAI'IvUTlC A(;ENT 499
In retropharyngeal abscess and in peritonsillitis {quinsy), as a
throat douche.
In earache, as a douche or by means of a hot-water bag.
In toothache, by means of a hot-water bag, or as hot water held
in the mouth.
In facial neuralgia, by means of a hot-water bag.
In prematurity, and in lowered vitality or reduced temperature
after disease, by hot-water bags or bottles.
Dry Heat. — Dry heat is used in the following conditions:
In prematurity, lowered vitality, or reduced temperature after
disease, by means of the electrotherm (page 46).
In suppression of the urine {acute nephritis), by the electro-
therm, or by hot air (page 346).
In using heat with children caution should be exercised as to the
degree employed. Serious burning accidents have occurred by the
use of hot-water bottles and hot compresses. When it is used very
hot, the hot-water bottle should be guarded by wrapping it in flan-
nel. Moist heat in the form of compresses, poultices, and stupes
should always be tested by placing the vehicles against the face of
the attendant. The adult hand will bear a greater degree of heat
than is safe, oftentimes, to apply to the skin of an infant or young
child. In using hot packs, hot-water bags, the electrotherm, or
dry heat, generated by a lamp or other device, such as the Kilmer
kettle (page 346), a thermometer should be placed between the
child's clothing and the bed-clothing. A temperature of 110° F. is
the highest to use with children. When water is the vehicle it must
be remembered that the patient must be most carefully watched
and the application frequently renewed because of the rapid evapo-
ration. A compress or poultice must not be allowed to get cool. A
piece of flannel or oiled silk or rubber tissue over a hot compress will
obviate the necessity for frequent changes.
COLD AS A THERAPEUTIC AGENT
In the treatment of children, cold is generally used in the form
of compresses, baths, or packs, and is indicated in the following con-
ditions :
In tonsillitis, acute pharyngitis , and headache, as a cold compress.
In meningitis and pyrexia by means of the ice-bag or the cool
coil.
In appendicitis by means of the ice-bag.
In endocarditis and pericarditis by means of an ice-bag.
In fever by means of baths, cold packs, sponging, and in older
children by colon flushings. (Not lower than 70° F. when used thus.)
In adenitis and in threatened superficial abscess by means of an
ice-bag.
500 THERAPEUTIC MEASURES
In hysterical and neurotic children as a spinal douche.
In malnutrition in older children as a tonic by means of a mod-
erate cool spinal douche following a warm bath.
For further details as to the application of cold for special dis-
eases the reader is referred to the discussion of the diseases in ques-
tion.
THE THERAPEUTIC VALUE OF CLIMATE
That climate is a valuable therapeutic measure in the treatment
of diseases in children is a well recognized fact. To my mind an im-
portant advantage of a change of climate is that it means more air
and better air. When patients go to a resort for climatic purposes
it is usually at no inconsiderable expense, and they are therefore
pretty likely to avail themselves of its advantages. The same
amount of air oftentimes could be furnished at home if the family
cooperation always could be secured. By the use of the window-
board, the roof-garden, and the indoor airing, we can to a consider-
able degree make a climate of our own. Nevertheless, in the ma-
jority of families the open-air treatment cannot be carried out suc-
cessfully; therefore the best interests of the patients are secured
when they are sent away from home. There are conditions also in
which such means as those just mentioned do not apply even if they
are carried out. We can give children warm air, and regulate the
temperature of the air in the winter; but, if they live in any of our
coast towns or villages, we cannot give them cool, dry air in summer.
Children who can be removed from a large city to the country, in-
land, for the summer, are invariably benefited, not only as regards
their food capacity and the ordinary influences of open-air life, but
they acquire also greater powers of resistance, and are thus less liable
to attacks from acute intestinal diseases. (See Summer Resorts,
page 491.)
During the colder months New York city children who are con-
valescing from pneumonia, pertussis, or any prolonged illness which
has greatly reduced them, will make a much more rapid recovery
when removed to Lakewood or Atlantic City, where open-air life
is more easily secured than at home. Infants and children suffering
from chronic digestive disorders, marasmus, and malnutrition, who
are given the advantages of climate or open-air methods either in the
home (page 147) or by a change of residence, invariably make a more
rapid recovery than do those deprived of it because of a lack of appre-
ciation of its value, or through fear of the child's taking cold.
Again, there are diseases in children in which the sudden change
of temperature, affecting the peripheral circulation, may be decidedly
harmful. Such conditions exist in slow convalescence from acute
nephritis, and also in chronic nephritis. These cases require an
equable climate, with a permissible outdoor life such as is furnished
during our colder months by Florida and Lower California.
PROMISCUOUS USE OF DRUGS BY THE FAMILY 50I
My experiences as to the effects of climate in asthma have been
contradictory. As a rule, cold climates and high altitudes such as
are offered by the Adirondacks, increase the asthma, particularly if
emphysema is also present. Nevertheless, I have seen patients who
were comfortable only when living under such climatic conditions.
From November ist to May ist the best results have been effected
in children by a change of residence from the cold and changeable
weather of the Middle and Eastern States to Lower CaUfornia or
Florida. Residence at the seashore has not been helpful to my pa-
tients. Older children whose parents can afford it should be sent to
a boarding-school, or to some other institution of learning located
where the climate is such as to guarantee freedom from attacks.
The best winter cUmate for a child with pulmonary tuberculosis
is a dry climate with a mild temperature, neither high nor low, but
with sunshine in such abundance as to permit a daily outdoor Hfe.
Such a cUmate is found in southern New Mexico and Arizona. These
places furnish conditions as near to the ideal as it is possible to
approach. The Adirondacks, while furnishing a climate in winter
which may be too severe for young children, answers well for those
from eight to nine years of age in w^hom the disease is not far ad-
vanced.
The sanitarium treatment is always advised if the patient can
afford it. Its advantages rest in the fact of the discipUne, the diet,
the amount of exercise, the sleeping quarters, the clothing — in short,
in all the details of life, every one of which is important. In a sani-
tarium all these matters are in the hands of those who are skilled in
the management of the disease, and who direct each case according
to its individual needs. Resorts for tuberculosis cases are dangerous
because of the possibilities of reinfection through the carelessness of
others. In a well-managed sanitarium, however, regulations regard-
ing expectoration and the care of the sputum reduce this danger to a
minimum. Sanitariums, however, are available to but few patients.
Many have not the means necessary to a change of residence, and
many others refuse to allow their children to be separated from
them, both of which facts necessitate the home treatment of a great
majority of the cases of pulmonary tuberculosis in young children in
our larger cities. (See page 287.)
PROMISCUOUS USE OF DRUGS BY THE FAMILY
While the giving of drugs to children by members of the family
is not to be encouraged, I find it wise to furnish to most mothers a
list of "permissibles." The love of people all the world over for
drugs and their faith in their efffcacy is so great that if they are not
supplied by the physician, they are very apt to secure them elsewhere.
If the reader has had an opportunity to look through the closets or
chests of his patients, where medicines are kept, he perhaps has been
502 THERAPEUTIC MEASURES
surprised at the number of preparations of proprietary and patent
medicines which met his gaze. The solution of the so-called "nos-
trum evil" would be very simple if every physician would take the
trouble to explain to his patients the character of — or, better, send
them a copy of the official analyses of — the various proprietary drug
preparations on the market. They should be convinced not only
of their worthlessness, but also of the dangers attending their use.
If mothers knew that most cough syrups and colic cures contain opium
or some of its derivatives, they w^ould not give them to their children.
Neither would they themselves take the various tonics and restora-
tives, "discoveries," and "bitters" in the market if they knew that
they contained a large percentage of alcohol. It is the duty of phy-
sicians to counteract, by teaching, the influence of the ingeniously
constructed medical advertisements in the daily and weekly press,
in both religious and lay periodicals. Not a little of what passes for
knowledge of diseases and their so-called treatment is thus obtained
by the layman through means that are intentionally misleading. It
has long been my custom to give the mother prescriptions for coughs,
for head colds, and for constipation. They are prepared and kept
on hand for use in case they are required. At the same time the
mother understands that I am to be called at once as soon as the
child has fever. In defense of this practice, which may be open to
criticism, I would state that I prefer to have my young patients take
the remedies I prescribe, and which are harmless, rather than to have
them run the risk of the administration of opium and alcohol, which
would be very apt to be the case if this precaution were not taken.
UNPALATABLE AND NAUSEATING DRUGS
It is impossible to mention in detail all the drugs which might be
included under this heading. Only those w411 be referred to which
we are obliged to use almost daily in our work — drugs which are
either unpleasant to the taste or which may be badly borne by the
stomach or drugs combining both these elements. How to admin-
ister certain drugs so that their use may be continued and yet not
interfere with the digestive function, is a question which deeply con-
cerns those who may have children for their patients. The element
of taste is a most important one in a child; therefore, when possible,
drugs disagreeable to the taste should be given to children in tablet
or pill form or in capsule. The continued use of a drug oftentimes
depends upon its being made palatable. As a general rule, when
pills, tablets, or capsules are given, one-half glass of water should be
taken at the same time, in order to diminish any possible irritant
effects upon the mucous membrane of the stomach.
Salicylate of Soda. — Salicylate of soda is a drug disagreeable in
taste and very liable to destroy the appetite and interfere with di-
gestion. In acute rheumatism its use is invaluable, and we are
UNPALATABLE AND NAUSEATING DRUGS 503
obliged oftentimes to give it in large doses. It is best given after
meals with one-half glass of milk. It is better to give fairly large
doses at this time, well diluted, rather than more frequent smaller
doses. It usually is better borne if given in solution with pepper-
mint-water or with simple elixir diluted 50 percent with water; but
the taste when thus given is only partially disguised, and being still
very objectionable to many, it may be given in capsule if the patient
is old enough, care being taken to give a considerable amount of water
or milk with each capsule,
lodid of Potash. — This drug is indispensable and is one for which
no other can be substituted. It is best given in solution. It is most
disagreeable in taste and a direct irritant to the mucous membrane
of the stomach. Like salicylate of soda, it should be given after
meals with from one-half to one glass of water or milk. It is best
given plain, using the saturated solution, which may be dropped into
the milk.
Bichlorid of Mercury. — This drug is usually given in such small
doses that its irritant properties are but little felt. It is best pre-
scribed in tablet form, dissolved in two teaspoonfuls of water and
followed by a swallow of water. When possible, it should be given
after feeding.
Alcohol. — Alcohol is another drug which should be given well di-
luted, regardless of the form in which it is administered. It is best
given with or after food, but it should always be given diluted with
at least six parts of water, if whisky or brandy is used.
Ipecac and Tartar Emetic. — Ipecac and tartar emetic, when em-
ployed as expectorants, are best given with sugar of milk in powder
or tablet form. They should never be given on an empty stomach.
Two or three teaspoonfuls of water should precede their adminis-
tration when they are not given within a reasonable time after
feeding. In many children, when given without this precaution
even in the usual doses, they will often decrease the appetite and the
digestive capacity.
The Ammonium Salts. — Carbonate of ammonia must always be
given in solution and should always be well diluted with water. Mu-
riate of ammonia may be used in tablet or powder form. Water or
milk should precede the administration of either. One part of
simple elixir with two parts of water make an agreeable combination.
Oils. — Oils used for nutritive purposes should invariably be given
after meals. Plain cod-liver oil or any of the preparations contain-
ing it should never be given on an empty stomach.
Castor Oil. — Castor oil is best given when the stomach is empty.
A much more prompt and satisfactory cathartic effect is produced
when thus given. It may be given in soda-water or coffee, with
orange-juice or in peppermint-water. Older children sometimes
take it better plain, sandwiched between the two halves of a pep-
504 THERAPEUTIC MEASURES
permint cream, first the candy, then the oil, followed by the remain-
der of the candy. If castor oil is vomited, it may be repeated in a
few minutes, and often will then be retained.
Creosote. — Creosote is most difficult of administration to many
children, I usually prescribe the carbonate, which is ordered to be
dropped into one or two teaspoonfuls of wine after meals. It may
also be given in soft capsules, or in an emulsion,
Quinin. — Quinin should be given in solution or in capsule, Quinin
pills as they are sometimes made, with an insoluble coating, pass un-
changed through the entire intestinal canal. When given in solu-
tion, a most satisfactory menstruum is a preparation of yerba santa,
known to the trade as yerberzine (Lilly), The bisulphate should
always be prescribed for children, for the reason that it may be given
in complete solution without the addition of acid.
Strychnin. — Strychnin on account of its taste is often strenuously
objected to, and is therefore better given in tablet triturate form.
If the tablet cannot be swallowed, it may be broken into small pieces
(not powdered) and mixed with a teaspoonful of orange pulp or in a
thick cereal jelly.
Digitalis, — Digitalis, when the tincture or the infusion is used,
should never be given when the stomach is empty. It should be ad-
ministered either after meals or follow the drinking of water or
milk. There are few drugs that will so completely destroy a child's
desire for food as the digitalis preparations when put into an empty
stomach.
Tincture of Muriate of Iron. — The tincture of muriate of iron
should be given well diluted after meals in at least one-half glass of
water. The child should take it through a glass tube so as not to
injure the teeth. In the use of the iron preparations generally, they
should be given after meals, and in case the hquid preparations are
used, thev should be well diluted with water.
GYMNASTIC THERAPEUTICS
The section on Gymnastic Therapeutics is included in order to
call the attention of general practitioners to the value of such work
and to assist them in applying necessary treatment. Exercises are
most often used therapeutically for children in the treatment of the
following conditions: Flattened or narrowed thorax, kyphosis,
scoHosis, flat-foot, congenital ataxias, and acute anterior polio-
myelitis; also in cases of habitual constipation, malnutrition, etc.
The following pages contain a description of the methods which
have been carried out most successfully with my patients by Dr.
Hugh Currie Thompson, New Rochelle, N. Y., to whose patience and
skill I am indebted for the recovery of many cases, some of which
had resisted other methods of treatment.
The family physician has an opportunity of seeing these con-
ditions at a much earlier stage than has the specialist, and at a
time when they may be more easily corrected than in later life.
When discovered, such conditions should never be neglected with
the idea that in time the child will outgrow them. Such a beHef
is often fallacious, for unless properly treated, they are apt to become
permanent. The necessity for the correction of physical defects
in children is readily appreciated by parents. Certain principles
or rules are involved in every form of practice. The following
principles are generally applicable in gymnastic therapeutics.
RULES
I. Examination. — As far as possible, obtain a complete history
of the case. Make both a general and a careful phvsical examina-
tion; under the latter, note the musculature, condition of the skin,
posture, any deviation of the spine, position of thorax and scapulae,
side lines of body, compare length of Hmbs, note the condition of
the feet. It is often advantageous to take the height and weight,
and certain measurements, such as girth of neck, chest, and waist,
and depth of chest and abdomen. In cases where the nervous
system is especially involved apply the tests usually made in such
cases.
II. Conditions under "Which Exercise Should be Taken. — (a)
Temperature of Exercise-room. — The temperature of the room should
be from 70° to 75° F. and there should be no draft upon the patient.
Therapeutic gymnastics involves fewer groups of muscles than ordi-
nary gymnastic work and the execution is slower. The general
505
5o6 GYMNASTIC THERAPEUTICS
circulation and respiration are not stimulated as much and there-
fore the heat production is less.
(b) Clothing. — In the beginning, the parts of the body involved
in the exercises should be devoid of clothing. A single thickness
of clothing may mislead as to the corrective effect obtained. At
frequent intervals, at least once a week, the child should be uncovered
for the purpose of observation during exercises. It is sometimes
desirable to have the clothing removed during each treatment.
At all times a child's clothing should be simple and hygienic, per-
mitting unhampered movements.
(c) Double Mirrors, etc.- — The use of double mirrors and a stringed
screen are sometimes desirable so that the child may see when he
has a correct position.
III. Frequency and Duration of Treatments. — Treatment should
be for an hour daily, Sundays and holidays excepted. This is not
too often, if the following points are considered :
(a) The length of time during which the condition has been
developing.
(b) The number of waking hours intervening between treat-
ments when faulty postures are apt to be maintained.
(c) That progress should be made as rapidly as possible, so that
the changed structure may be the basis for the period of growth.
Many times this rule must be modified, owing to the physician's
lack of time and the expense to the patient's family. From an
hour's supervision daily it may mean supervision by the physician
only once every two weeks, supplemented by careful home super-
vision fifteen minutes daily. This arrangement should be the mini-
mum of attention given to anv case.
IV. Prescription of Exercises. — (a) Forms of Exercise. — No cer-
tain system of exercises need be followed as long as the exercises
used have an anatomic and physiologic basis. Both active and
passive movements are used with and without resistance. Exer-
cises with resistance given by the physician are used much in cor-
rective work, for in this form of exercise the physician can easily
judge as to the amount of exertion and increase or decrease it at
will.
(b) Accuracy of Execution. — Accuracy of execution of each and
every exercise given in the prescription is essential. A possible
exception to this might occur in the treatment of such cases as mal-
nutrition or constipation, where exercise per se is the essential thing,
but even in these cases conditions may be such that very careful
work is necessary. A prescription of exercise in itself means little.
The manner in which it is executed may actually aggravate the
condition, as the wrong muscles may be made stronger by a faulty
manner of execution. In writing out a prescription of exercise the
physician should be guided by the patient's capability for fairly
RULES 507
accurate execution of each exercise. This cannot be gaged by the
physical examination alone, but the examination must be supple-
mented by having the patient try the exercise for one or more days.
Unless he can approximate the proper execution without assuming
faulty positions or postures and without causing too much nerve and
muscle fatigue, simpler exercises should be used. As the patient im-
proves or becomes stronger, more difficult exercises should be given.
In advancing, the rule regarding accuracy should be observed.
Exercises have several details which need to be watched in order
to secure accurate execution. At first do not confuse the child
by requiring absolute accuracy as to every detail; rather select one
or two of the more important ones and insist upon the most rigid
observance of these. As the child grasps and retains these ideas
and is able to carry them out, require more, until all are mastered.
(d) Concentration. — Frequent repetition of the exercises is nec-
essary to obtain desired results. In repeating an exercise many
times, a child easily forms the habit of executing it with but little
effort, which will soon result in inattention and carelessness. When
this occurs bring about an increase of exertion on his part bv insist-
ing that every detail be mastered, or change to more difficult exer-
cises.
(e) Ovenvork. — If a child is fatigued at the end of an hour's
rest following the treatment, he has been overworked, and the exer-
cises should be made less difficult. A certain amount of muscle
soreness must be expected during the first few davs of work.
(/) Rest. — In many cases the child should rest in a recumbent
posture for half an hour after the treatment, and in nervous cases
the treatment should be preceded by a half hour's rest.
(g) General Health. — Attention should be given to everything
that will build up the general health of the patient, such as bathing,
sleep, fresh air, general exercise, diet, dress; suitable furniture (chairs,
tables, or desks, etc.) should also be considered. Attention to these
things will sometimes shorten the time of treatment by eUminating
causative factors.
V. Adaptation of Exercise to Practical Ends. — Adapt corrective
positions to all practical ends: walking, sitting, working, or playing.
VI. Cooperation. — Endeavor to secure the cooperation of mem-
bers of the household, teachers or servants, between exercise periods
in order that the progress of the child may be as rapid as possible.
A child is not at first capable of adapting the work to practical ends
without careful oversight of elders.
VII. Period of Treatment. — There are two objects in treatment:
One which should always be obtained, that of improvement; and
the other complete and permanent correction, which should be the
aim until an insurmountable obstacle is reached. To gain these are
required, continuous and conscientious work, and the cooperation of
5o8
GYMNASTIC THERAPEUTICS
those in charge of the child and of the child himself. As a rule,
these objects cannot be obtained in a short period of time.
After the treatment has been completed the child should be
brought for examination every three months.
POSTURE AND BREATHING
Posture and breathing will first be considered, as they hold an
important place in the correction of the conditions about to be con-
sidered. A good posture should be maintained
during all exercises. Between treatments the
child should maintain as good posture as his
condition will permit. TelHng him to do this
is not sufficient, but he should be given exer-
cises which will strengthen the weakened and
overstretched muscles and stretch the con-
tracted ones, and thus enable him to assume
an improved posture. The work for correct-
ing posture should be taken up gradually.
Have a child hold a good posture for short
periods of time, beginning with one minute
and working up to fifteen minutes. The child
should be taught to assume and maintain a
good posture during the entire day, no matter
what he is doing, whether at work or play.
In the standing posture the weight of the
body should be brought forward until it rests
over the balls of the feet or over a point mid-
way between the toes and the heels. In sit-
ting, the weight of the body should be carried
over the posterior third of the thighs.
For general posture, my rule consists of
the following steps: Heels together, or ap-
proximately so, knees well stretched; chest
raised high ; head erect with chin in (stretch
up entire body as high as possible) ; poise
weight forward over balls of feet; bring
shoulders back and down. The feet should be
turned outward slightly or kept straight.
(See Fig. 55.)
In the above rule do not relax any pre-
00. v^j^^.^n,^«.. xw=,.- vious step as a new one is taken. In sitting,
insist that the hips be pushed well back in order
that the child may not slide forward so as to bring the weight of the
body over the lower spine.
From the beginning, an attempt should be made to improve the
posture. Take the essential details for the child to follow and in-
POSTURE AND BREATHING 509
crease the requirements as fast as practicable. These individual
details have been tersely expressed in different ways, and one ex-
pression may convey the idea of the detail more clearly to one patient
and another expression to another. For instance: "Chest Up!"
may mean that you wish the child, if he has relaxed, to take the
best possible posture of the thorax. In taking a good position of
the thorax, there should be no raising of the shoulders, no conscious
taking in or holding of the breath, and the trunk should not be
inclined backward nor the pelvis or abdomen permitted to project
forward.
General Considerations. — i. When children use bicycles, veloci-
pedes, mail wagons, etc., where they propel themselves by pedal-
ing, they should not ride with head and shoulders forward and chest
contracted to gain advantage and leverage, but should have the
body inclined forward from the hips, back straight, and chest ex-
panded.
2. Improper and insufficient diet, poor assimilation, lack of fresh
air, and disturbed sleep cause a loss of general tone, which tends to
make a child relax and assume bad postures. All these matters
should receive attention. See Tardy Malnutrition, page 158.
3. Cloihing should be examined to see that it causes no pressure
or tension. All garments should be loose and simple. The
underclothing should be elastic and light in weight. The stock-
ings should fit the feet and should be supported by soft elastics
extending from V-shaped pieces at the side of the waist, which catch
the stockings on the outside of the legs. The shoes should have
flexible soles, a fairly straight line on the inside, a low broad heel,
and should be broad enough to permit the toes to spread. So
much depends upon the condition of the feet, both in standing and
walking, that they should receive as careful daily attention as the
hands. Hats should first be for protection. They should be light
in weight and should come far enough forward to protect the eyes
from the sun, and should never be worn far enough back to make
the child tilt his head to balance the weight, or to make him bend
it forward to protect his eyes from the sun. Outside wraps should
be sufficiently light in weight and flexible enough to permit free
movement in walking or running.
4. Sleep. — A child should not form the habit of sleeping always
on one side with the knees drawn up to the chest, but change from
side to side. If the posture is very poor, he should for some time
sleep on the back with limbs extended, and without a pillow. The
mattress should be thin and firm, and the child's covering light in
weight, and only a small pillow used.
5. FurnUure. — The furniture a child uses, especially his chairs,
tables, or desks, should be adapted to his age and height. Furniture
not properly adapted to children is one of the main causes of bad
5IO
GYMNASTIC THERAPEUTICS
posture. Chairs should have the height of seat correspond to the
length of the lower leg. The child's feet should rest comfortably
upon the floor, and there should be no pressure under the knee.
The depth of the seat should be no more than the length of the
thigh. If it is greater the child tends to sUde forward, and assume
a bad posture with the weight of the trunk over the lower spine.
The back of a chair should not have upright spindles, but cross-
pieces, or, at least, one cross-piece sufficiently high above the seat
to allow the fleshy part of the hips to project underneath it in order
to bring back the tuberosities of the ischii far enough to support the
weight of the trunk in a good position. The lower cross-bar, pre-
ferably adjustable, should support the back at the junction of the
Adjustable Table, Dr. Mosher's Chairs, Board, Ladder, and Blocks for
Ataxic Exercises.
dorsal and lumbar vertebrae. In addition there should be another
cross-bar to support the upper back.
Dr. Mosher's kindergarten chair, sold by The Milton Bradley
Company, ii East i6th Street, New York city, is the best chair
for children that has come to my attention. It is constructed in
three sizes, with seats ten, twelve, or fourteen inches in height, but
there is no lower cross-bar for the support of the back. If the
seat of a chair is hollowed out. there should be no raised border at
the back, as it would prevent the hips from being pushed well back.
If well-constructed chairs cannot be obtained, ordinary chairs may
be modified for use in the nursery or for older children, by selecting
those having a cross-bar several inches from the seat and sawing
POSTURE AND BREATHING
511
the legs off. If the scat proves too deep, a pillow may be placed
between the child's back and the back of the chair, but it should not
extend below the waist-line.
6. Heredity.— Parents often attribute a bad posture with flat
chests or other physical deformities to heredity, saying that a
child "takes after" one parent or the other. Heredity is usually
only a shght factor, i. e., the child may inherit a frame or general
constitution or certain
mental and physical
characteristics resem-
bling those of a parent,
but the faulty posture,
flat chest, etc., are in
most, if not all, cases
acquired. A well-nour-
ished infant has a
straight back. In a
well child, you seldom
see a flat chest before
the age of three years.
7. In very young
children, the deformity
is often induced by the
position assumed in
play. For instance, the
sitting position on floor
or bed with legs ex-
tended and spine bent
forward, which most
young children assume
in playing, keeps the
chest in a bad position
for long periods of time
day after day. This is
especially true if, for
any reason, the back
muscles are not as
strong as usual and can-
not easilv maintain the
weight of the trunk in
an erect position. For
children who are kept in bed when not seriously ill, a folded blanket
or air-cushion may be used as a seat, and a bed table or tray, for
playthings and meals. A support may be used for the back if needed.
Fig. 56 shows Dr. Mosher's chair and an adjustable table,
may be made for use in the nursery,
Chest raising agai
which
The top of the table, 2^ by
512
GYMNASTIC THERAPEUTICS
4 feet (or 3 by 5), is made of well-seasoned boards h inch in thick-
ness. These boards are held together by quarter-inch pegs and
holes, as are the leaves of an extension dining-table. Two sets of
light-weight wooden horses (legs f by 2 inches and cross-pieces i
by 2^^ inches) are used for supports: one set, for use when the child
is seated, 14 to 18 inches in height; the other, for use when standing,
24 to 30 inches in height. If desired, the whole may be painted
white or stained and varnished. For reading there should be a
book-support for the child's books, so that he may keep his head
erect.
8. School Hygiene. — Physicians as well as parents should interest
themselves in school conditions, as often it is in school that the child
Fig. 58.— Posture Exercise.
Arching body.
contracts bad postures, because of the long hours of confinement,
unsuitable desks and seats, and frequently by a lack of proper
ventilation.
Exercises. — The following exercises may be used for correcting
postures.
1. The child stands with toes from 2 to 4 inches from a flat per-
pendicular surface, as a closed door. Tet him assume a good stand-
ing position ; sway the body forward from the heels (heels kept on
floor) until the chest touches the door; but neither the abdomen
nor head should touch it. (See Fig. 57.)
2. Raise arms sideways to shoulder height; lift heels; stretch
up with head and chest, in with chin, and out with arms.
BREATHING 513
3. The child Ues on his back on a fairly hard, flat surface. Place
your hands under his head, raising it an inch or two. lie then,
reclining as before, arches his body from head to heels. (See Fig.
58.) The knees should be kept straight. In the beginning, as
in figure, he may aid himself with his hands in arching body.
Later the arms should be folded lightly on the chest.
4. The child standing, should raise arms sideways, turn palms
up at shoulder-height, and continue to raise them until the hands
are midway between horizontal and vertical; sway bodv forward;
stretch up with chest and head, in with chin, and out and up with
finger-tips.
5. Clasp hands, back of head. Raise chest well and press head
backward, chin in, resisting with hands. Keep elbows well back.
Walking Movcmenis. — Have patient walk on balls of feet, with arms
extended sideways, shoulder high, maintaining a good posture. When
capable of doing this satisfactorily, repeat with arms raised over
head; arms should be well stretched, fingers straight, palms facing
and separated by the breadth of the shoulders.
BREATHING
The primary object of breathing is to aerate the blood by carry-
ing oxygen to it by the air that enters the lungs; secondarily, through
the practice of deep breathing, the accessory muscles of respiration are
developed, the breadth and depth of chest and the lung capacity
are increased. In deep respiration the amount of air taken in
is several times that inhaled in ordinary respiration. The amount
inhaled in "tidal" respiration by an adult is 30 cubic inches, while
that which can be taken in by forced inspiration is from 150 to 300
cubic inches. Daily practice of deep breathing in the open air
helps to increase the resistance of the lungs to diseases to which they
are liable.
A mistake is sometimes made in overdeveloping the chest mus-
cles, so that the chest becomes to a certain extent "muscle-bound,"
and the expansion is lessened, instead of increased. There is little
danger of this when the development comes from taking deep inspira-
tions rather than by muscular activity alone. While a development
of the chest muscles is desirable, they should not be developed at the
expense of the normal expansion of the "respiratory chest." The
aim should be to improve the molnlity of the chest and the lung
capacity as well as to strengthen the muscles.
Two kinds of breathing are usuallv spoken of: ihoracic and ah-
dominal. Breathing should be considered as a whole, unless one
form is especially lacking, as, for instance, where a child has a very
flat chest in which diaphragmatic or abdominal breathing greatly
predominates over the thoracic, and there is little mobility in the
upper part of the chest. If the abdominal breathing needs to be
33
514 GYMNASTIC THERAPEUTICS
developed, have the child stand in a good posture, with hands placed
lightly over the lower ribs, with tips of the fingers two or three inches
from the median line, and take long, deep breaths until he secures a
good movement of the lower ribs. The hands are placed over the
ribs, only for the purpose of feeling the movement.
All breathing exercises should be taken with the body in a good
position and may be done while standing, lying, sitting, or slowly
walking. Ordinarily they are taken in a standing position. If
the muscles are weak or if it is difficult to stand in a good position,
they may be taken in a sitting or reclining position. When the
breathing exercise is taken reclining, a couch or a board resting on
two chairs may be used in preference to a bed or the floor. A small
hard pillow or a folded bath-towel may be placed under the shoulders
and upper back, but should not extend under the head. Snch a pad
is used with advantage in cases of kyphosis and lordosis.
It is better to take the deep breathing exercises in the open air,
on the highest elevation in a nearby park, or during the daily
outing, or even while walking to and from school, or while driving.
But one must adapt himself to existing conditions, and if taken
at home they may be taken on a piazza or balcony, or even
indoors, with wide-open windows, but the air should be as free from
dust as possible. If the windows are open in winter, the child should
wear extra wraps or clothing.
A breathing exercise should be preceded by a number of strong,
sharp exhalations through the mouth, in order thoroughly to empty
the lungs of residual air, so that the deep inspirations may fill the
lungs with fresh pure air.
The clothing should always be loose with no constrictions at
neck or waist.
Holding the breath at the end of full inspirations may be done
to advantage, if it is not held longer than five seconds. Retaining
the air after full inspiration causes it to become warmer. As
it becomes warmer it expands and penetrates the better into the
alveoli. Retaining the air from one-half to one minute or longer
is not wise. Becoming warmer, it continues to expand and may
overdistend and rupture the alveolar walls. Prolonged holding of
the breath has also a deleterious effect upon the heart.
If, when the child begins to take deep breathing exercises he
feels dizzy, he should not at first fill the lungs to their greatest
capacity, or hold the breath, and each deep inspiration should be
followed by several ordinary ones. After a few days the dizziness
usually ceases.
In all cases, deep breathing and respiratory exercises should be
given. They are of special value in malnutrition, constipation,
flat chest, and scoliosis.
Breathing Exercises. — ^Take a good standing posture.
BREATHING
515
1. Inhale deeply and exhale slowly.
2. Place hands lightly on lower chest. Inhale deeply; exhale.
3. Place hands lightly on upper chest, elbows well back and down.
Inhale deeply; exhale.
4. Inhale as arms are raised sidew^ays to shoulder height. Ex-
hale as arms are lowered.
5. Inhale deeply as arms are raised forward and upward, to a
vertical position. (From the beginning have elbows, wrists, and
fingers straight, palms facing each other and separated by the
breadth of the shoulders.) Exhale as arms are lowered sideways.
Fig. 59.— Breathing Exercise.
Inhale as arms are raised, sideways, upward, to vertical.
6. Inhale as arms are raised sidewavs to vertical. (Elbows,
wrists, and fingers straight — turn palms up when arms are shoulder
high.) As vertical is reached, bend head sHghtly backward, stretch
up and continue inhaling, while you slowly count three. Raise
head; exhale as you lower arms sideways. (See Fig. 59.)
In the illustration the wrists are strongly flexed and the palms
are not turned, in raising to vertical. The action is stronger. Either
position of the hands may be used.
5l6 GYMNASTIC THERAPEUTICS
7. Arms at sides, elbows, wrists, and fingers extended. In one
quick, continuous movement raise arms forward and flex forearms
upon the chest, palms down, elbows drawn well back. At the
same time a step forward is taken — the weight of the body is sup-
ported over the forward foot, the ball of the other foot resting on
the floor. With the above movement inhale deeply. Exhale as
the arms are lowered to side.
In Nos. 4, 5, 6, and 7, above, put the emphasis on the upward
movement. In lowering the arms, keep chest high and arms well
stretched, but make the movement an easy one.
If the heart is weak, in the above exercises the arms should not
be raised above the level of the shoulders, and all the exercises
should be done more slowly and with less exertion. If the breathing
becomes labored, or the countenance shows signs of interference
with circulation, the child should rest until pulse and respiration
return to their usual rate.
Where deep respiration is an end in itself, in addition to the
preceding breathing exercises, others which favor involuntary deep
breathing should be given. It is important that a good posture
be maintained throughout.
Exercises for Younger Children. — i. W^alking up-hill at a mod-
erate pace without stopping.
2. Running in place, i. c, executing a running movement with-
out advancing.
3. Distance running — from fifty yards to a mile. The minimum
distance to begin with, and the maximum distance to work up to
in accordance with the general condition and age of the child.
4. Running games, such as rolling a hoop, playing tag, etc.
Exercises for Older Children — in addition to those just mentioned :
1. Games, such as hand-ball, basket-ball, tennis, and football
as played by boys.
2. Swimming for distance, when accompanied by a competent
person in a boat.
FLAT CHEST
In flat chest the weight of the body is usually carried too far
back, the abdomen and head being too far forward. The chest is
flattened, with ribs depressed, and there is interference with the
proper expansion of the lungs. The shoulders often droop forward.
The posture is one of general relaxation.
Flat chest is of common occurrence among children during the
years of school-life. It should be carefully corrected on account of
the deleterious effect on the lungs and abdominal organs. The
necessity for its correction should be impressed upon the child.
Attention to posture and breathing is essential. The aim should
be to give exercises which will strengthen the muscles of the back
and neck, deepen and broaden the chest, and increase its elasticity
FLAT CHEST
517
In addition to the exercises given under
[ have found the following of benefit in
and breathing capacity.
Posture and Breathing,
these cases :
I. Have the patient lie prone on a hard, flat surface, hold the
ankles while the patient raises head and chest as far as possible;
the arms extended and raised with the body, the backs of the hands
being turned toward each other with the thumbs up. In the first few
treatments, the thumbs may be clasped. Hold position for from two
Fig. 60.— Back Exercise.
Raise head and chest high.
to five seconds, or while counting from one to five or ten. (See
Fig. 60.)
2. With knees straight, bend trunk forward until the hands touch
the floor in front of the toes, or come as near to floor as possible,
then raise the body to best possible standing position. Keep weight
well over balls of feet, raise the chest as high as possible, stretch
the arms well down at the side; wrists, fingers, and elbows straight.
Hold this position for from two to five seconds or while from five to ten
are counted. The primary value of the exercise is in the elevation of
the chest; secondarily, the back muscles are strengthened and, in
bending forward, the muscles that elevate chest are relaxed so that
they are better able to give a strong contraction when the body
is raised.
3. Have patient seated on a stool or low chair and stand be-
hind him. Patient swings straight arms forward upward to vertical \
palms facing. He then turns palms forward and grasps your hands
and pulls his elbows backward and downward close to sides. As
he pulls them downward resist his movement.
KYPHOSIS
Kyphosis, as considered here, is an increase of the normal curve-
in the dorsal region of the spine, commonly called "round-shoulders," '
produced by weakened muscles and bad habits of posture, or some-V
Fig. 61.— Chest Exercise.
Stretch arms strongly.
times by improperly arranged clothing, and by the occupation of the
child. These causative factors should be removed as far as possible,
and, as in all the deformities of childhood, attention should be
given to posture, breathing, arrangement of clothing, etc. ■
The treatment given under Flat Chest is appropriate here, as the:
two conditions are often associated. The following exercises may
be added:
1 . Raise arms sideways to height of shoulders. Bend head back-
ward with chin drawn in and at same time turn palms strongly
upward. When patient has learned to do this well, as the head'
goes back the arms may be raised to vertical.
2. Flex forearms upon chest, palms down and elbows well drawil.
KYPHOSIS
519
back, shoulders level. Incline head slightly backward and fling
■X arms forcibly sideways.
3. Raise arms sideways to shoulder level, turn palms up, make
three short circles with arms, stopping at the backward movement.
Raise arms a few inches, stretch out and up. Bring arms backward
and downward to sides. (See Fig. 61.)
4. Hanging exercises :
A short curtain-pole i|
inches in diameter may be
placed in a doorway at
desired height. Strong
enough sockets can be ob-
tained at a hardware store.
(a) Hang with over-
grasp.
(6) Hang and swing-
Hanging, is of much
value in kyphosis and flat
chest on account of its
effect upon the spine and
spinal muscles.
(c) Holding patient (see
Fig. 62) ; trunk of pa-
tient resting against your
body.
(d) Holding patient;
upper back resting only
against body.
Exercises "c" and "d"
are used for the passive
stretching of the lumbar
and dorsal portions of the
spine. The dependent part
of patient's body acting as
weight to stretch the spine.
Hold from one- fourth to
one-half minute. Repeat
several times.
5. Patient sitting on
stool or chair with arms
forward midway between horizontal and vertical, palms facing.
Make resistance as arms are separated backward and downward.
(See Fig. 63.)
6. Forearms flexed upon upper arms, hands closed and facing
the front of shoulders. Strongly rotate forearms outward and
backward. (See Fig. 64.)
62. —Weight of Pelvis and Lower Lime
TO Stretch the Lumbar Spine.
520
GYMNASTIC THERAPEUTICS
7. Patient sits astride a stool and raises the arms sideways. With
an assistant, either the child's mother or nurse, on one side and
yourself on the other, grasp the patient's hand with one hand and
place the other hand on his back in the region of greatest deforniitv
Have the patient pull the elbows close backward and downward to
the sides, against resistance. At the same time gentle and firm pres-
sure is made on the back.
8. Patient sits on stool, places hands low on hips, fingers for-
ward and wrists straight, elbows drawn well back. Let him bend
Fig. 63.— Sit behind Patient and Give Resistance on Back of Wrists \s Hi Separates.
His Arms. ,
forward from hips with back straight. Place your hands over the^
regions of greatest deformity and have patient raise the body against?
resistance. The back must be kept straight, head erect, and chest-
well arched. When the patient can do this well, his hands may'
be placed on the back of the neck, instead of on the hips.
9. The patient stands, raises arms sideways, shoulder high,*!
bends trunk forward from hips, back straight, and raises arms ta^
vertical.
10. Patient lies face downward over end of couch or table, the
whole body straight, hips and thighs only, resting on table and held*.
SCOLIOSIS
521
Hands back of neck. Bend body forward until the chest touches
the seat of a chair, then raise body as high as possible. (See Fig. 65.)
1 1 . With children who are not strong, begin with exercises in a
reclining posture:
(a) Reclining position. Arms extended at right angle to the
body, palms facing each other. Separate arms against resistance.
(b) RecHning position. Arms extended beyond head in line with
the body. Bring arms sideways, downward, against resistance.
(c) Deep breathing.
(d) No. 3 under Posture Exercises, but body arched only from
hips upward, instead of
from heels.
The spinal muscles
should be massaged to
make them pliable. ^^
i
SCOLIOSIS
Scoliosis, or lateral
'fcurvature of the spine,
is a condition in which
the spine deviates in
whole or in part to one
side or the other of the
median Hne. It is ac-
companied by the rota-
tion of the vertebrae,
though in some cases the
amount of rotation is so
slight that it is not easily
detected; in other cases
the rotation is marked
in comparison with the
amount of lateral curva-
ture.
The treatment of cur-
vatures resulting from
such diseases as tuber-
culosis or caries of the spine, rickets, etc., will not be considered,
but only the simple curvatures which occur in. cases of general
debihty, muscular weakness, or are the result of faulty habits of
posture, a short leg, certain occupations, etc.
Diagnosis. — In the treatment of scoliosis, much depends upon a
careful diagnosis. As far as possible all the etiologic factors should
be ascertained: the heredity, general constitution and tempera-
ment of the patient; the general appearance, condition of
skin, the musculature, its structure and tonicity, should be closelv
Fig. 64.— Bring Forearms Back as Far as Possible.
522
GYMNASTIC THERAPEUTICS
scrutinized. The patient's habits of posture while standing and
sitting, especially when he is unconscious of observation, should
be studied carefully. Inquiry should be made as to position during
sleep, and if a school-child, concerning the desk, and chair and posi-
tion while writing, etc.
For examination the back should be bared down to the^
level of the trochanters, when the height of shoulders, height^
and prominence of hips, position of the scapulae and their relation
to the spine, the lines running from the tips of the cars to
the tips of shoulders, and the position of arms as they hang at the
sides, should all be noted. The position of the spine itself and its
relation to points mentioned should also be closely observed, when
•Fig. 65.— Movement May Start from Position of Complete Flexion or Partial Flex-
ion WITH Body Resting on Seat of Chair or on Shorter Stand or Tauli:.
the patient is standing in his usual posture, and again when he is,
standing in his best possible position. The position of the spinous
processes should be marked with a flesh pencil and the curve carefully
studied out; the contour and relative size of legs should be noted '
and the feet should be examined. To ascertain the amount of rota- ,=•
tion, the patient should be made to take the Adam's position.^ If any '■■
difference is found in the height of the hips, a careful measurement of
the legs should be made. Another important point to be determined '
is the flexibiUtyof the spine, for to a great extent the diagnosis depends
upon this. "j
On the front of the body, the position of ribs, end of sternum,
umbihcus, and the tension of the abdominal muscles should be hoted. ^
> Patient stands with heels together, well stretched, bends body forward' ■
from hips; head and arms hanging forward. •■'
scouosis 523
Besides the above examination, it is well to inquire into the
history of the patient, as to diseases of childhood, present ailment,
liabilit}^ to certain diseases, as to amount of exercise both outdoors
and indoors, and as to the condition of the digestive organs. Ex-
amine heart and lungs. Certain measurements may be taken, such
as height, weight, height sitting, girth of neck, chest, waist, hips,
biceps, calves and insteps, depth of chest and abdomen, and breadth
of shoulders, chest, and waist.
I have found the best method of recording to be by photographing
the patient, using a thread screen, the spinous processes and lower
border of scapulae having been outlined with flesh pencil or dots of
ink. To record the rotation, a lead tape may be molded across the
posterior thorax at point of greatest convexity, while the patient is
in the Adam's position, and the tape carefully removed and its out-
line traced on paper.
The curve may be a single long curve, a double, or a triple one.
Endeavor to find out which is the primary, and which the secon-
dary or compensatory curve, for the normal position of the spine is
the result of the adjustment of the weight of the body around the
center of gravity, in order to balance the body while standing or
sitting, and if there is a change in the normal adjustment of the
weight in one part, there must soon be a corresponding change else-
where, so that if there is a left convexity in the lumbar region there
will be a compensatory curve to the right in the dorsal.
Treatment. — The treatment should be both general and local.
In the general treatment, carry out a thorough hygienic regime,
which includes exercise in the open air, baths, attention to diet and
bowels, clothing, and general light exercise for muscle-building and
stimulation of the circulation, respiration, and digestion. One of
the most important things is to train the habits of posture.
Special Treaimeni. — Massage and exercises which act strongly
upon the spine itself, and suspension, with and without pressure, I
have found most useful. It is occasionally of benefit to have a
patient wear a plaster cast or leather jacket during the day, between
treatments.
At first only general movements are given, those in which both
sides of the body are used equally, such as those found under Posture
and Breathing, and adding, a little later, the exercises under Flat
Chest and Kyphosis, with simple movements of the body to
strengthen the spinal muscles and make the spine more flexible.
The following may be used: body-bending forward, backward,
to right and to left, and body-twisting to right and left. These
movements may be done sitting or standing, and with the hands
at the hips, back of neck, or extended over head.
'In' giving a new exercise, the body should be bare, in order that
its effects may be carefully noted.
524
GYMNASTIC THERAPEUTICS
tHiw*
In giving corrective bending and twisting movements, the bend- '
ing should be toward the side of the convexity with added pressure
at the point of greatest curvature, and the twisting movement
toward the side, of the concavity with pressure over the point of the ■
convexity. The following are some of the special exercises: ^
A typical S-shaped curve, convexities, right dorsal and left i
lumbar, has been taken to illustrate the treatment. These exer- ]
cises can be reversed. A single or triple curve will have to be :
studied out with back
bared.
1. Hanging from bar;
pressure over convexities.
(See Fig. 66.)
2. Hanging from bar.
Place your hand over .■
point of greatest con-
vexity, and push pa-
tient's body sideways.
3. Hanging from bar.
Have patient extend the
leg corresponding to the
side of lumbar convexity
backward against resist-
x»n»^_^^^^ ance.
• ^Si^S^^I^^IV^ 4' Ly^^S prone on,
_'•<' ^^^^^*M^^^^Bl' table; left hand ow-^
-'^^^^^^Bl neck, right on hip: raise
^H^^^^^L body. (See Fig. 60, but
"* with hands placed in
accordance with text.)
5. Lying prone on
table; hands on neck/
Carry patient's legs to-
ward the convexity of
the lumbar region.
6. Patient sits astride
a stool; hands back of
neck. Twist body to left;
make pressure over right
dorsal region.
7. Sitting on stool; left hand back of neck, right at hip; right
leg extended backward. Bend body forward : resist patient as he
raises body, using pressure over convexities. (See Fig. 67.)
8. Standing: flex forearms on upper arms, with fingers pointing
over shoulders. Extend left arm upward and right arm downward
and backward, and extend left leg backward.
Fig.
66. —Spine Being Stretched by Weight of
Body, Pressure over Convexities.
SCOIvIOSIS
525
9. Using wand, that is about twelve or fourteen inches shorter
than the height of the body; grasp at ends, with elbows straight;
swing strongly from front of thighs to the right, sideways, backward,
until the wand is at a perpendicular and in line with the spine. The
body arches from heels to head. (See Fig. 68.)
"Key-note position."^ I^eft arm extended upward; right arm
sideways. (See Fig. 69.)
Fig. 67.— Body Raising with Pressure over Convexities.
10. (a) Take "key-note position" standing. Stretch body for
from two to five seconds.
(6) Take "key-note position." Marching on balls of feet.
Do not give more than three or four special exercises in any one
treatment, and follow each of them with a marching exercise, such
as 10-6, or some breathing exercise,
best posltioT^ position is the position of arms by which the spine assumes its
526
GYMNASTIC THERAPEUTICS
CONGENITAL ATAXIAS
The ataxias of childhood, to which we refer, are hereditary cere-
bellar ataxia and hereditary spinal ataxia. Most observers have"^
described them as beginning to develop at the age of eight or teiL^
Fig. 68.— Swing Strong-
ly TO This Position
WITHOUT Bending El-
bows.
Fig. 69.— Key-note Position.
Arm corresponding to low shoulder is raised. Used.?!
to maintain a better position of the spine during certain. '^
exercises and marches. f
years; one or two observers have mentioned a much earlier iieriod,,.U-
stating that the s^'^mptOms generally appear at the age of three or.i'
four 3'^ears, and that the cases ma}^ be congenital, -.:
Cases upon which this treatment is based were congenital; the
development of the physical movements was retarded and defective
CONGENITAL ATAXIAS 527
from the beginning, and in one case of hereditary spinal ataxia the
physical act of nursing was also defective.
Hereditary cerebellar ataxia is characterized by the involvement
both of the upper and lower limbs at the same time, although the
upper limbs may not be ataxic to the same degree as the lower.
The gait is reeling, uncertain, with the feet wide apart, body bent
forward, the weight of the body being supported mainly upon the
balls of the feet, the toes inclining inward, locomotion at times being
interfered with by the crossing of the legs. One leg is usually
more ataxic than the other. The reflexes may be increased. The
speech is hesitating, defective, and explosive, but audible.
Hereditary spinal ataxia (Friedreich's ataxia) is characterized by
its beginning in the lower limbs, gradually extending to the upper
limbs, and finally involving the organs of speech. The symptoms
are vertigo ; swaying from side to side on standing ; marked muscu-
lar weakness, especially of the extensors and abductors (paralysis
may follow) ; contractures of the flexors and adductors ; scoliosis
and talipes resulting, first, postural, through muscular weakness,
later becoming fixed; rheumatoid pains; and diminution or loss
of the patellar reflex; the head is held to one side in a clonic spasm,
but turns from one side to the other every day or two; one leg is
more ataxic than the other. The movements are characterized
by rigidity and incoordination; the articulation is scanning- and
explosive, and oftentimes, for days, the patient cannot speak above
a whisper.
Dana states that there may be a mixed or transitional heredi-
tary cerebellar and spinal ataxia.
Some observers state that there is defective mentality, and that
the patients possess a violent temper. I have not found either to
be true — the temper being no different from that which you would
find in a httle patient otherwise ill for as long a period, and who was
not perfectly understood. The speech, or the poise of the head,
may suggest deficient mentality, but I have found these children
affectionate, observing, and rational, and showing hereditary indica-
tions of brightness in mechanical, mathematical, or methodical lines.
In beginning treatment, study the patient's capability for co-
ordinate action. Do this throughout the entire course. When
you have decided upon the exercises to be given, show them to the
patient in detail, explaining them fully, so that he may understand
what effort is required, and occasionally, in teaching, repeat these
illustrations and explanations.
Accuracy is of the first importance. If there is lack of control in
movement, pause and hold patient in correct position while you count
from one to four or ten before resuming movement. Follow that
practice as long as it is necessary, and at every tendency toward
losing control. Slow and accurate work first, later more rapid work.
528 GYMNASTIC THERAPEUTICS
While learning an exercise of coordination permit patient to use
his eyes to watch his limbs, in order that the coordinate centers
may thus be reinforced or aided. Next rely only upon his muscular
sense for correct execution, and at last have the eyes closed in order
to eliminate the relationship of surrounding objects, which might
aid in the execution. A reclining posture is assumed for coordinate
training, where the patient is unable to stand.
Do not expect a child to cooperate with you in attention or efforts
to make his physical movements accurate when he is left to himself
for it is rarely done. The coordination must become reflex.
The training must be carried to the extent of unnecessary capability.
"The keynote " must be, as with the orthopedist, over-correct, for
the correct execution of work under observation would not be suffi-
cient to insure coordinate action, the moment a child attempts to
do things alone, or when he is tired, or when his attention is given
to other objects.
The aim in treatment should be in keeping with a child's natural
sphere in life. Childhood is the time of muscular activity and growth ;
it is the period of play and games. When a child is able to play at
all, if left to himself he will not stop, for rest, when he begins to tire
or fall ; he will do so only when the game is ended, and his companions
finish. Play, therefore, serves only to increase the incoordination,
because of overexertion. To make a child capable of walking or
running at all, makes him eager to play when others play ; but it is
like the fencing or boxing of two men, one of whom completely
outclasses the other, whose native quickness and strength are com-
pletely overcome ; he has neither the opportunity to show them nor
the mind to use them. The ataxic child, in playing with normal
children, besides tiring more quickly, being outclassed, becomes
bewildered and cannot seize the opportunity to attempt coordinate
action.
No satisfactory results can be expected from the treatment of
ataxia, unless it is continued until the child is able to play as well as
other children. The treatment should be made practical as soon
as possible. Do not spend unnecessary time on gymnastics or
apparatus. When a child shows that he is able to take one step,
begin walking exercises, going up and down stairs, and running.
Study the patient's movements, and analyze his defects in execu-
tion. To tell a child not to fall when he is walking, and expect him
to be able to avoid falling, is not fair to the child. He does not know
why he falls, and his attempts to avoid it only increase his gen-
eral nerve tension. His faffing may be due to one of several causes:
it may be that he is walking with his feet widely separated; if so,
he gets but little support from the advancing foot, and upon fatigue,
diverting of attention, or striking a small obstacle, he will fall.
When he permits his feet to separate, he should at once be directed
CONGRNITAL ATAXIAS 529
; to keep them close together. By so training the child, it will become
; easier to keep his feet in position, and, if there is no other defect,
t falling will unconsciously be avoided. So all of his work must be
I analyzed to discover its weaknesses or defects.
I General gymnastics have no place in the treatment of ataxia,
but where certain groups of muscles are weak, movements may be
given to strengthen them, in order that they may do their part in
coordination. Throughout the greater part of the treatment I
i have used exercises for strengthening certain groups of muscles,
although their primary value was not to improve coordination.'
It is well to have these movements executed against resistance, in
order to determine the amount of muscular power the patient pos-
sesses.
Coordinate efforts at balancing and walking are first made upon
the floor until the child shows a little improvement, but it is
difficult to make a child reaUze the necessity for using all of his ener-
gies in the effort, when he knows that there is no particular danger;
therefore apparatus is necessary to force coordination. Boards,
blocks, and ladders (see Fig. 56) are used, not for the purpose of de-
veloping ability to perform exercises upon them, but to develop un-
consciously the habit of constant care and watchfulness, as the child
can readily appreciate the fact that, without such precaution, he will
slip and fall ; he also learns that he cannot relax, whenever he is inclined
to do so, as he might were he on the floor. By this apparatus work,
children unconsciously acquire the abiHty to control themselves in
places of danger into which their play leads them.
Always place some incentive before the child, as otherwise he
rarely puts forth the necessary exertion. His interest, attention,
and muscular and nervous energy must be exerted. Tell him that
it is necessary to do a certain amount of work before the treatment
is over; that, when a certain amount is done, the treatment for
the time will be over, whether the hour is up or not. Tell him that
he must do something more than he did the day before, whether
it takes longer than the hour or not. If it takes longer than the
hour, he will learn that you mean what you say, and sometimes
the entire work of the hour will be executed in the last few minutes,
despite the fact that the fatigue of the previous efforts makes it
more difficult.
While we wish to avoid fatigue, a certain amount is harmless.
If a child remains fatigued at the end of an hour's rest, following
the treatment, and he does not coordinate as well as before the
treatment, provision should be made for more rest during the next
treatment. A child's inertia needs to be overcome in spite of
fatigue. It will teach him that merely saying he is tired wdll not
"enable him to escape the work. This has iaeen impressed upon me
by seeing how, after fifty-five minutes of unsuccessful effort, a child
34
530
GYMNASTIC THERAPEUTICS
will "pull himself together," as it were, and do a new exercise thai-
may really be difficult, in order that he may be able to leave at tl
end of the hour.
Never permit a child to suffer a fall or injury during the treat-
ment. Never take any risks with your patient. (See Fig. 70 ) %
Falls cannot be prevented in ordinary walking, or running, except-l
by words of caution, which should always be used; however, thev^
should not be used in tests when the patient is endeaA^oring to see i
-how far he can walk or run before he falls. On the first fall, make ^
him return.
Experience teaches a patient distrust of his abihty to do a thing'
Fig. 70.— Walking on a Narrow Board Several Feet above the Floor.
An advanced exercise in coordination.
which he has never tried, or, having failed after several trials, he
will naturally say he cannot do it, and not wish to attempt it. Con-
fidence must be inspired in him to follow directions unhesitatingly
by insisting upon his accomplishing every task given him, and thus
proving his ability to do it, and also by showing him that his interest
is yours, and that you have never permitted him to be injured dur-
ing his unsuccessful attempts.
With a child it is not enough to secure coordinate action, but
you must secure endurance along the lines of reflex, coordinate
action. Coordinate action with one \\'ho is ataxic calls for general
tension, and the unnecessary accessory action of groups of muscles
CONGENITAL ATAXIAS 53I
is fatiguing, and results in excessive waste of nerve and muscle
energy. To teach a child to do his work easily and to carry on
prolonged coordinate effort is thus accomplished by the same means.
A parallel can be found in a person learning to skate or swim. Here
we have a general tension and the general action of all the muscles
of the body — a great waste of energy to prevent one from falUng,
or going under the water — and even after one has learned how to
swim, much of that nervous waste of energy will continue until
he has thoroughly mastered the art. Endurance and conservation
of energy are very desirable in an ataxic.
After he had been in training for several months one patient
walked forward, without stopping, five hundred feet on the top of
a fence, and backward one hundred and twenty feet without stop-
ping. The same child walked several miles up and down a moun-
tain-side without stopping, his mind occupied with observation
and not applied at all to his walking, save in response to caution.
He was able also to run half a mile without stopping or falHng. It
is not for the purpose of making the child a long-distance walker
or runner that, after he has learned to walk or run properly, the
distance is gradually increased to one or more miles, telling him to
"take it as easy as possible" without stopping, although when
fatigue is noticed sufficient rest should be given — it is common to
see normal children of three or four years of age run and play
for long periods of time without apparently tiring — our object in
endurance exercises is to fit the patient for a child's sphere in Hfe.
Gradually the muscles become inured to fatigue, do their work
with a minimum expenditure of force, and to a certain extent re-
cuperate while in action.
Short periods of retrogression must be expected occasionallv
throughout the entire course. When a child is tired, has had excite-
ment, or when he is indisposed, one must expect a temporary loss
of coordination. Parents too should be prepared for this, and not
be disheartened when it occurs.
The life of an ataxic child should be quiet and free from excite-
ment. Judgment should be used about allowing him to mingle
with other children, even though they are members of his own
family. When allowed to play, it should be with younger children,
if possible, or with his nurse, or mother, until the time of playing
with other children is made a part of the treatment, and even then
it should be confined to lines permitted by the one in charge. In
the intervals, a child needs sufficient quiet and rest, so that he will
completely recuperate, and be in the best possible condition for the
next treatment, as the treatments afford the only hope of restoring
him to nerve stability and normal muscular movement. As he
improves, however, the daily regime should vary. As a rule, a
child should rest, lying down from one- half hour to an hour before
532 GYMNASTIC THERAPEUTICS
treatment, and the same length of time after treatment, and, in
fact, at any time during the day when incoordination becomes
marked.
Attention to the general health of the child is important. There
should be a simple and nutritious diet, careful attention to the bowels,
daily bathing, an outdoor life, taking the treatment whenever possi-
ble in the open air. These things should not be neglected, as these
patients are apt to have less resistance to disease than non-ataxic
children.
Illness does not cause a retrogression except temporarily through
the weakness which follows it. With returning health and strength,
progress continues.
Cooperation is important. It is more necessary here than in
any other chronic ailment. A child will recover in one-half the
time if cooperation is conscientiously given by those in charge of
the child. For illustration: the child is capable of walking, but
walks on the balls of his feet, or crosses his feet frequently, causing
him to lose his balance easily; whenever he does it, if he is called
back, no matter what his object may be for going, until he has
walked across the floor correctly, the next time he starts to walk
it will not be necessary to call him back as many times, and the con-
stant correct walking will gradually make it a reflex habit. If he is
permitted to walk incorrectly it encourages incoordination and a
careless habit. The course of nervous stimuli has been likened to
the making of a new path in a jungle. Constant use will make it
easy to travel, but if the old path of incoordination is used instead,
the new path of coordination remains a difficult task for a much
longer period of time. The lines of least resistance are followed,
and the new must be made as easy as the old if we would have a
child use it.
Treatment should be for an hour daily. More than an hour's
treatment is apt to produce general nervous fatigue. An ataxic child
may need training along many lines, and the attempts to do one
thing correctly may require so long a time that it is unwise to at-
tempt to give work for the correction of all at one treatment. If
this is attempted, nothing will be well done in the hour, and the
work will only serve to tire the patient and increase the incoordina-
tion. It would take a normal person, who could do the movements
well, more than one hour to cover all the lines with improvement in
each. An hour has been spent in endeavoring to walk a plank once
without falling off, but the child did it before the treatment was
completed, and the next day he did it twice, so there was evident
progress. When one morning hour is given to the lower limbs, work
might be mapped out so that an assistant, the mother or nurse, could
give another hour, or half hour, in the afternoon to exercises for the
arms and fingers, or to massage, which would improve the nutri-
CONGENITAL ATAXIAS 533
tion of the tissues and the general circulation, so as to insure a
better general response of the nerves and muscles. Another half
hour could be spent in training the speech of the child. In this way
the correction of the upper Hmbs and speech could progress at the
same time as that of the lower limbs, instead of waiting until after
the coordination in the lower limbs is first secured.
Improvement in one line does not imply any special improve-
ment in another. Walking, running, going up and down stairs,
jumping, and hopping must each be taken up separately. It is
particularly true, in case one is working for improvement in the
lower limbs, and Httle attention is given at the same time to the
upper. At the end of the time devoted to locomotion, the ataxia
of the upper limbs is but little improved.
Parents and physicians occasionally think that a child will out-
grow his ataxia, but this is a mistake.
A patient should hold as good a posture as possible at all times,
as the weight of the body is then better adjusted. One or two
exercises under Posture should be added to the treatment. The
suggestions about clothing, under Posture (page 509), are especially
valuable here.
Five or ten minutes once or twice a day should be devoted to a
sitting posture in which the body is held erect, but the limbs relaxed,
and every part of the body entirely at rest. This aids greatly in
overcoming the nervous instability and irritability, and is a valua-
ble help in securing general nervous control.
When giving the patient his treatment there should be no one
else in the room, unless it is one whose presence would aid in securing
better attention or work from the child.
There is difference in the treatment of congenital ataxias and
that of locomotor ataxia: In one case the patient is a child, in the
other an adult. With the child, between treatments there is little or
no cooperation; with an adult there is cooperation. During the
period of development a child's sphere is that of play and muscular
activity. The adult looks forward only to returning to his busi-
ness or professional activity, and stops treatment when his pro-
ficiency and coordination permit this.
Exercises. — In the beginning, when the child cannot walk, ex-
ercises should be taken while lying down. For the lower limbs,
they consist of coordinate flexions and extensions, abductions, ad-
ductions, and circumductions, actively and against resistance, and of
touching certain designated points or objects with the feet separately.
In cerebellar ataxia one can more readily advance to the standing
exercises, and take foot-placings (floor may be marked for this),
stepping out to side, front and back and to the ordinary oblique
positions, forward and backward. The weight of the body is carried
by the advancing foot, so that when the movement is completed
534 GYMNASTIC THERAPEUTICS
the weight rests equally over both feet. Taking a step is now prac-
tised, bringing up the other foot to the side of the foot advanced.
This is done sideways, forward, and backward. Two or three steps
are now attempted, a pause being made after each one until a per-
fect poise of the body is obtained. This is continued until the child
can walk across the room. At this time the defects shown in the
walking should receive attention.
The defects in walking or running are usually the following:
carrying the weight of the body too far forward; not straightening
the knees completely; the reeling gait; the crossing of the legs;
walking with the feet separated ; turning the toes inward ; not lifting
the feet sufficiently; not bringing the heels to the ground. As
occasion arises, show the child his defects, and caution him against
their repetition. In walking and running in the room, repeat the
exercise if any faulty execution is noted. Instruct the members
of the household, who have charge of the child, never to ignore
these defects, but always to insist upon their immedia,te correction.
In the outdoor walking or running, the patient should always be
in advance of you, so that his every movement may be observed.
It is here that the correction of the defects should mainly take
place. The following four movements aid in correction, and should
be given every day for quite an extended period, in order that the
weakened muscles may be strengthened for the required work of
coordination :
(a) Drawing up the knees against resistance ;
(b) Flexing the toes against resistance ;
(c) Abduction of feet against resistance;
(d) Extension of legs against resistance.
In the full extension of the legs, the feet must be kept flexed.
The child being able to walk across the room, work is begun upon
the apparatus ; boards from 7 inches down to i inch in width by half
an inch in thickness and 10 feet in length, of well-seasoned hard-
wood; a ladder, the sides of which are i^ by 2^ inches, 10 feet in
length, and the rounds | inch in diameter by 12 inches long, placed 10
inches apart in the ladder ; 24 blocks of wood, 2 inches in thickness
and 12 inches wide by 14 inches long. Beginning with the 7-inch
board, have the child walk over and back, with the arms in different
positions, the eyes open and the eyes shut; one end of the board
placed upon one block, and so on until one end is resting upon ten
or more superimposed blocks. The board is placed upon supports of
equal height, beginning with one block under each end, increasing
the height until the board is about five feet from the ground. At
each increase in height the various exercises are repeated. (See Fig.
70.) Two five-inch boards can be used when placed upon the'
same supports, the boards being about eight or ten inches apart.
The child can step from one board to the other, going from one end
CONGENITAL ATAXIAS
535
to the other; and, standing in the center, he can step forward and
backward from board to board. With boards placed together, walk
forward and backward, the boards bending unevenly, as one foot is
on each board.
Using the blocks alone, arrange them for walking, at varying
distances from each other; also make piles uneven in height, and
have patient walk with the eyes open and the eyes shut on the blocks.
Fig. 71.— Walking on Rounds of Ladder, One End Raised Several Feet above Floor-
AN Advanced Exercise in Coordination.
Ladder Exercises. — Ladder fiat on the ground, walking forward in the
spaces between the rounds; walking sideways and walking backward.
Place one end of the ladder upon a block and add blocks gradually
until the ladder reaches the height of the child's knee ; then begin
536 GYMNASTIC THERAPEUTICS
with both ends of the ladder placed on single blocks, gradually in-
creasing the height until the ladder reaches the height of the knee ; after
each change of height the walking exercise forward, sideways, and
backward is repeated. When using the blocks the child may bring
them from the pile and build the steps that he is to walk upon;
standing upon the block previously placed upon the floor, he bends
forward, placing in position the one he carries, repeating the process
until all the blocks are arranged. When through walking over the
blocks, he stands on the one next to the last one placed, bends over
and picks up the last one, and may carry it back to the pile, walking
over the blocks, or he may lift and raise it above the head, and pass
it, either forward or backward, to you. The block may be carried
by the child walking through the spaces of the ladder, and both
ladder and blocks may be arranged in various forms to be walked
over by the child.
You may now take up the balancing work, where the weight of
the body is carried on only a portion of the sole of the foot, as in
walking on the rounds of the ladder. The ladder is first placed flat
upon the ground, and the walking is done forward and backward.
This is graded by raising one end of the ladder until the child can
walk up and down on the rounds several times without a mistake,
the ladder raised to an angle of 35°. (See Fig. 71.)
In beginning the treatment, the child is instructed not to allow
one foot to step directly in front of the other. By this time co-
ordination is sufficiently mastered so that balancing as an exercise
may be taken up, using the boards from 2 inches down to one inch
in width. On these boards the child must place one foot in front of
the other, and walk forward across it; next, walk backward, eyes
open and eyes shut.
When a child is able to walk fifty or sixty feet without falling or
stopping to rest, the distance is gradually increased in outdoor
walks, correcting defects when noticed, until he can walk a miile or
more without their occurrence or without falling.
When able to run across the room in a straight line, teach running
in a circle. W^atch closely his running and do not allow the feet to
be widely separated, or the weight of the body to incline too much
forward. He should run with a firm stride and raise his feet well. In-
crease distance until he can run half a mile without falling or stopping
to rest. Later teach running up and down hill ; running short dis-
tances, as from eighty to one hundred feet, as fast as he can, and stop-
ping without falling; trying to catch a person; racing with another
child, who starts at a sufficient distance behind him, so that they
will finish at about the same time ; running to catch a person who
will dodge and run zig-zag and in circles. Playing with other chil-
dren in running games, such as "cross-tag," "pull away," etc., hav-
ing the other children so handicapped that by exerting himself to the
CONGENITAL ATAXIAS
537
utmost he will not be caught. During these games, if he falls, he
should be obliged to run around the grounds once alone.
Other indoor exercises are: whirhngononefoot fifty times without
falling; repeat on the other foot ; alternate thus with eyes open and eyes
shut ; running in a short circle fifty times without falling. Such exer-
cises are helps to the running out of doors. Another helpful exercise
is running several hundred feet out of doors, whirling around in
the direction indicated whenever the command "turn right," or
"turn left," is given, without falling.
Walking Up and Down Stairs. — Begin wuth one or two steps and
gradually increase until the length of the flight is reached, seeing
that the feet are not separated, but that they advance in straight
lines directly in front of the body. In walking up stairs, carry the
weight of the body over the foot that is on the upper stair. In walk-
ing down stairs, be sure that the heel is brought against the back of
the stair, so that the foot at no time will rest on the edge. Keep the
hands close to the sides of the body while walking up and down stairs
with the eyes shut. Run up and down stairs with the eyes open
and again with eyes shut, carrying articles W'hile running. Always
be near enough to the child for his protection in case of accident.
The object is to train the muscular sense and make the coordination
sufficiently reflex to enable the child to run or walk up the stairs
alone without the danger of an accident.
Jumping. — Draw a line with a piece of chalk; teach the child
to inchne his body sHghtly forward, bending knees a Httle, spring
forward, aided by an upward swing of his arms. Jump for height
and distance over the rounds of the ladder, from one space to another,
and repeat, skipping one space. Jump from block to block, the
blocks being separated at varying distances. Jumping over blocks;
running and jumping.
Hopping. — Hopping is much more difficult, as the spring is from
one foot alone, and the landing on the same foot. In addition to the
coordination necessary to balance upon one foot, is added the required
effort to lift the body from the ground and the coordination required
for balancing the body on landing, so as to avoid falHng. The
training is about the same as in jumping; hopping with either foot
over a string; hopping for distance ; hopping for height ; and making
a succession of hops on the same foot, without touching the other
foot to the ground ; the running hop.
At the close of these exercises it may not be amiss to repeat what
was stated at the beginning, that it is not desired to make the child
an athlete, but distance walking, distance running, fast running,
jumping, and hopping are exercises which children use in their play
for long periods of time, and the coordination secured by the appa-
ratus work is often of value in places of danger where their play is
often apt to lead them. Coordination to this degree should be secured.
538 GYMNASTIC THERAPEUTICS
Exercises for the Upper Limbs. — In the beginning, the general
movements of the fingers, wrists, forearms, upper arms, and shoulders
may be practised, executing them slowly until the coordination is
perfect in these movements. The above exercises are simple move-
ments of flexion, extension, rotation, and circumduction. The
educative movements, however, have mainly to do with the fingers.
1. Flexing and extending the fingers.
2. Slowly and gently touch the tip of the thumb to the tip of
each finger and hold them together without pressure while five is
counted.
3. Simultaneously touch the tip of each finger to the tip of the
thumb.
4. Flex strongly the index-finger so that the end will touch the
base of its second metacarpal bone.
5. Flex strongly and adduct the thumb so that the tip of the
thumb will press the tip of the little finger.
6. Flex strongly and adduct the thumb so that its tip will press
the base of the little finger.
7. Needles: have them graded from the largest to the smallest
size, grasp a fine thread between thumb and each finger of one hand
in turn, and thread each needle ; repeat, using the other hand.
8. Buttons: have them graded from the largest to the smallest
obtainable, and have them sewed on to one strip of cloth, another
strip of cloth having buttonholes to correspond. Practise buttoning
and unbuttoning with thumb and index-finger of each hand.
9. Pins: picking them up with hand. Pick up the pins and press
them through a stiff pasteboard box, forming various designs.
10. With a pencil correctly held, make squares, triangles, parallel
lines, etc., with and without dots as a guide.
11. With a pencil correctly held, make figures and letters both
large and small.
The child can also use the exercises of piling coins and chips,
touching hanging balls, placing pegs in holes, and similar games.
Also throwing and catching a ball. A child should be made to dress
and undress himself, and to feed himself, although as exercises,
at the beginning, he may do them only in part.
In eating, the spoon or fork should never be full, and the cup or
glass should be only partly filled. The execution of the move-
ments should be slow.
Exercises for the Speech. — A child should be taught to enunciate
numbers and letters distinctly. An interesting book should be read
to him, reading one or more words at a time, and requiring him to
repeat them correctly after you.
Friedreich's Disease. — In a well-marked case, begin treatment with
massage to improve the nutrition of the weakened and atrophied mus-
cles and to help relax the spasm in the contracted muscles. In con-
ANTERIOR POLIOMYELITIS 539
nection with the massage, passive exercise of the Hmbs is given and
gradual and persistent extension is made upon the contractures,
endeavoring to gain a Uttle each day until the limbs are fully ex-
tended; then increase from day to day the time during which the
hmb is held at full extension and abduction. The degree of motion
in the joints is utilized by giving active movements. In order
that the muscles may become stronger, slight resistance is given to
these movements, and greater attention paid to the strengthening
of the weaker groups of muscles. When the muscles have moved
the limbs as far as possible, the extension must be completed by
stretching or by pressure. A child should be taught how to turn
over, after pushing up his arms out of the way. When lying
prone he should try to draw up his knees under his body, and when
his arms become flexible enough and strong enough, he should raise
up his body until he rests on his hands and knees; later he is
required to raise himself until he is sitting upon his legs, which are
flexed underneath his thighs. Have patient raise his body from a
reclining to a sitting posture, with legs extended. Let him sit in
a chair, which is low enough to permit him to place his feet upon the
floor, but without any supporting arms. Let him rise from a sitting
to a standing posture by drawing back his feet underneath him,
and inclining his body slightly forward, then straightening up to a
standing posture. Have him balance, upon standing, from a few
seconds to several minutes, stretching his body up to its full height.
Give foot-placings, then let him attempt a few steps, pausing after
each step to straighten up, balance and "make himself tall." From
this point the treatment is the same as that of the ataxia of the cere-
bellar type, except that the massage and work for overcoming the
contractures must be continued indefinitel)^, or the progress will
be slower.
ANTERIOR POLIOMYELITIS
Exercises should include action of all the groups of muscles of
the limbs. The exercise of the muscles that are normal, or but
little impaired, stimulates the nutrition of the neighboring impaired
muscles.
With the patient in a reclining position the thighs may be flexed,
extended, abducted, adducted, and circumducted against resistance
when possible. The leg may be flexed and extended, and the foot
may be flexed, extended, abducted, and circumducted. These move-
ments ma}^ be passive at first; later, when possible, they may also
be taken standing. Flexion and abduction of the foot and extension
of the toes are results which will come last.
A faint response is sometimes seen after friction over the super-
ficial points of the nerves supplying these muscles, or when the
limb is immersed in hot water, and when seen the movements should
540 GYMNASTIC THERAPEUTICS
be completed passively. As the muscles show signs of returning
functions, the movements are repeated frequently during the day,
but always stopped when the responsive motion becomes weaker,
in order that fatigue may be avoided. When possible, the lightest
resistance should be given, so that the power of the muscles
may be better ascertained, and their work thus gradually increased
by increasing the resistance. An added stimulus may be given by
having the normal limb execute the movement with the paralyzed
limb. Occasionally, movement is secured in all but one toe. Where
there is improvement in any way in the paralyzed limb, the treat-
ment should be continued, for cases have shown that muscles may
respond to treatment even though there may be no faradic reaction
for more than a year.
When the patient is able to walk, walking and marching exer-
cises should be taken up, such as walking on straight lines to and from
certain objects, walking on the toes, walking with the arms sideways
shoulder high, and with arms in a vertical position. The blocks,
board, and ladder that are used in treating ataxic patients pre-
viously described are of use here. A trough or the use of a narrow
ladder with sides six or eight inches in width serves to help the
patient overcome the outward throw of the paralyzed leg. Although
the dimensions of the ladder are different, the walking exercises
outhned in the treatment of ataxia may be followed in part. In
walking, the patient should endeavor to keep the foot flexed as much
as possible, touching the heel first in bringing down the foot. The
following may also be given: walking on the heels for a short dis-
tance; jumping; cHmbing a ladder, using hands and feet; running,
but do not permit an outward throw of the paralyzed leg, it must
advance straight forward; hanging from a bar, swinging both legs
forward, sideways and backward, keeping heels together, and with
feet apart. A light basket-ball or foot-ball may be used for kick-
ing. Have patient practise the drop-kick, and show you how hard
he can kick.
Exercises for the Arms. — Flexion, extension, abduction, adduc-
tion, and circumduction of the upper arm; flexion, extension, and
rotation for the forearm and wrist, with and without resistance.
Have patient close hand as tight as possible, showing how hard he
can strike. Have him catch a basket-ball and practise throwing
it into a high basket at different distances. Drop a tennis-ball into
his hands to catch; also toss and bound it for him to catch. Have
him throw a tennis-ball for height and distance. The tendency is to
throw the ball downward. Some of the special finger movements used
in the treatment of ataxia, such as approximating the tip of the
thumb and the tips of the fingers, the button exercise, the work with
the pencil, etc., may also be given. (See page 538.)
Passive Exercises. — Where there is any tendency to contracture
CONSTIPATION 54I
in the groups of muscles not paralyzed, or in which the degree of
paralysis is only slight, passive exercises should be given to secure
a normal range of motion of the contracted groups either in leg or
arm. This must be kept up throughout the treatment for the pur-
pose of lessening or overcoming the tendency to deformity. Care
should be used, however, in not carrying the passive motion beyond
the normal range.
Resistance applied to movements of contracted muscles serves
to stretch them more than does the passive stretching.
Massage. — Gentle, deep-kneading, light clapping and hacking,
friction over the superficial points of the nerves, and general fric-
tion should be given to the entire limb.
Light hacking, vibration, and deep-kneading should be given
to the spinal muscles.
Fifteen minutes of massage should be given once or twice daily
as long as the treatment is needed.
CONSTIPATION
In addition to the measures suggested in a previous section (pages
170-175) for the rehef of constipation, gymnastic exercises may
be brought into use.
These exercises are given with two objects in view: one, to
strengthen the abdominal walls, which mechanically stimulate the
intestine; the other, to stimulate the general circulation, which
quickens the portal circulation and increases the activity of the liver.
The first five exercises are taken from a reclining position.
1. The knees straight and feet extended. Raise both legs until
they are at a right angle with the body.
2. Knees straight. Raise heels about four inches above couch;
separate them as widely as possible ; bring them together, and lower
to couch.
3. Knees straight. Raise heels ten or fifteen inches above
the couch. Draw up the knees as close to the chest as possible,
without raising heels. Extend the legs without raising or lowering
the feet. Lower legs to couch.
4. Feet held, or secured by strap. Raise body to sitting position
without use of hands. The hands may be placed upon the thighs,
folded upon the chest, placed back of neck, or the arms may be ex-
tended beyond the head. Changing the position of arms in the
order named increases the exertion.
5. Feet held. Circle trunk sideways, forward, sideways, back-
ward to the starting position. Starting to right and left alternately.
Arms position as in number four.
6. Hang from bar or round of ladder. Execute No. i. (The
position of body changed, but the relation of legs to body same as
in No. I.)
542 GYMNASTIC THERAPEUTICS
7. Hanging position. Execute No. 2.
8. Hanging position. Execute No. 3.
9. Hanging position. Heels together, swinging legs from waist,
describe as large a circle as possible with the feet.
Each of the above exercises may be followed by a deep-breathing
exercise.
In a weak patient, the detail of straight knees need not, at first,
be insisted upon. If necessary, the patient may be assisted, the
weight of the legs or body being partly supported until the patient
is strong enough to execute it alone.
10. Sitting on chair or stool. Hands placed back of neck, twist
body right and left against resistance.
11. Sitting position. Hands back of neck, bend body right
and left against resistance.
Exercises for the General Circulation. — Taken from a standing
position.
1. Bend trunk forward, touch floor with fingers, keeping the knees
straight.
2. Take a long step forward, bend the forward knee; bend trunk
forward; touch the floor with fingers. Raise trunk, step back to
position. Alternate feet in stepping.
3. Stand with feet two foot-lengths apart. Raise arms side-
ways to shoulder height. Bend right knee and bend trunk to right
side, touching floor with right hand. Raise body. Same to left.
4. "Chopping." Stand with feet separated, fingers interlaced.
Bend body forward, swinging hands to floor between feet. Raise
bodv, swinging hands up over right shoulder, at same time twisting
to right. Swing to floor. Same to left.
5. Hop, feet apart, then together, quickly.
6. Run in place — i. e., without advancing.
(a) With front of thighs kept in same plane with front of body,
heels striking buttocks in running.
(6) With each step in running, raise the knees as high as possi-
ble in front of body.
The running and hopping should be done quickly, and continued
long enough to get the body thoroughly warm.
Passive Exercises. — i. Trunk-rolling. Patient in a sitting posi-
tion, feet separated and fixed. Grasp him by the shoulders, and
with a continuous movement bend the body to the right, forward,
left, back to the starting position. After the movement has been
given several times, reverse the direction.
2. Thigh-rolling. Patient in a semi-reclining position. Grasp
patient's foot with right hand, his leg just below the knee with left.
Raise thigh and circumduct it, the knee describing as large a circle
as possible.
FLAT-FOOT 543
Exercises with Resistance. — i. Reclining position. IHcx and ex-
tend thighs.
2. Semi-reclining position, with knees drawn up. Abduct and
adduct thighs.
The prescription for treatment may be arranged in this order:
active exercises, passive exercises, exercises with resistance, ending
with some deep-breathing exercises.
FLAT-FOOT
Flat-foot is a condition in which the ligaments and muscles
of the foot are abnormally weak, and in which the anterior posterior
arch may be partially or wholly depressed and flattened.
The leg is rotated inward and the foot everted; the weight of
the body falls on the inner side of the foot; the interior malleolus
is prominent; the entire sole of the foot rests on the floor; and
when the feet are placed side by side and the toes and heels touch,
the natural concavity of the inner line of the foot is replaced by a
convexity. The patient complains of pain or weakness, and the
tissues of the sole are weak and flabby.
There are different methods of examining the outlines of the
sole of the foot: standing with the foot on a plate of glass so that
the sole of the foot may be seen from beneath; smearing the sole
with vaseHn and standing on a piece of blotting-paper; smearing it
with charcoal and standing on a piece of white paper, etc.
The patient should have proper rest. He should frequently
sit with feet elevated, and avoid exhaustion. When standing, he
should occasionally invert the feet, and, when walking, walk with
the feet parallel, as the Indians do, and for short distances walk
on the outer borders of the feet.
The feet should be cared for each day, giving attention to the
nails and to bathing. Apply hot and cold water alternately, and rub
vigorously in order to stimulate the muscles and the circulation.
The feet should be properly clothed; the stockings should be
even, smooth, and loose, but should not heat the feet. The shoes
should be broad enough to permit free use of the muscles of the feet ;
the toe of the shoe should point sHghtly inward, and the inner border
may be raised; the heels should be low and broad.
The general condition of the patient should be carefully considered,
his general tonicity — for its impairment will affect the condition of
the feet. Judgment should be used in the care and use of the feet
in rheumatism, and during and shortly after convalescence where
there is a general relaxation of muscles and ligaments. Malnutri-
tion and obesity, if present, should receive attention while the feet
are being treated.
In severe cases, in the beginning, the patient should be kept en-
544 GYMNASTIC THERAPEUTICS
tircly off of his feet, and given only passive exercises, massage, and
bathing.
Exercises. — i. RecUning or semi-recUning position. Extend foot
against resistance.
2. Reclining position. Adduct and invert foot against resis-
tance.
3. Reclining position. Circumduct foot inward, upward, and
outward with resistance applied to the inward and upward motion.
4. Standing position. Raise on toes.
5. Standing position. Raise on toes ; turn heels outward ; lower
heels slowly to floor.
Passive Exercises. — i. With one hand hold heel firm, at the same
time pressing on the astragalus with an outward, upward motion
of the thumb, while the other hand adducts, everts, and flexes the
foot. This may be done under hot water if the deformity is marked.
2. Extension of foot.
3. Adduction of foot.
Massage. — Deep-kneading, vibration, and clapping may be given
to the foot and to the muscles of the calf of the leg.
A gauze pad may be placed under the arch, and held by adhesive
plaster or a rubber bandage, until a well-fitted plate can be made,
which should be used for support in the intervals between treatments,
until the muscles and ligaments have gained sufficient strength to
hold the arch in a normal position.
DRUGS AND DRUG DOSAGE
FOR INTERNAL USE
Drug.
ACETANILID.
Not advised in the treatment of chil-
dren.
Acid, Arsenious. See Arsenic.
Acid, Benzoic. Benzoic Acid, Flowers of
Benzoin
Used in cystitis of alkaline type
Acid, Gallic.
Bismuth Subgallate. (Dermatol.)
Used internally as an intestinal astrin-
gent, also externally,
Acid, Hydrochloric, Dilute. (Corre-
sponding to 31.9% of absolute
HCl.)
Used in chronic gastritis with atony
of the stomach
Acid, Lactic.
Used in fermentative diarrheas.
Given best well diluted with syrup and
water and at 2-hour intervals
Acid, Phosphoric, Dilute. (Containing
10% Orthophosphoric Acid.)
Used as a stomachic
Acid, Salicylic.
Seldom used uncombined.
Bismuth Subsalicylate.
Intestinal astringent and sedative . . .
Methyl Salicylate. (Synthetic Oil of
Wintergreen.)
Antirheumatic
Oil of Wintergreen. (Natural.)
Antirheumatic
Salol. (Phenyl-salicylate.)
Intestinal antiseptic and antirheu-
matic
Sodium Salicylate.
Antirheumatic
Aspirin. (Non-officinal.) (Acetyl-sali-
cylic Acid.)
Antirheumatic, — a substitute for So-
dium Salicylate, being less irritating to
the stomach. Best given in capsules,
for it is decomposed by alkalies and by
moisture
Acid, Tannic.
Used in the form of:
Tannalbin. (Dried Albuminate of Tan-
nin.)
Used as an intestinal astringent ....
35 545
6 Months. 18 Months. 3 Years. 5 Years.
gr. 1
gr. 3-5
gt. i-*
gtt. 1-2
gr. 1
gt. 1
gt. 1
gr. 1
gr. 1
gr. 1-2
gr. 1-2
gr.5
gt. 1
gt. 1
gtt. 2-3
gr. 1-2
gtt. 2-3
gtt. 2-3
gr. 1-2
gr. 1-2
gr. 1-2
gr. 1-2
gr.2
gr. 10
gtt. 2
gtt. 2
gtt. 5
gr.2
gtt. 3
gtt. 3
gr.2
gr. 2-3
gr. 2-3
gr. 2-3
gr. 3-5
gr. 10
gtt. 3-5
gtt. 3-5
gtt. 10
gr. 3-5
gtt. 3-5
gtt. 3-5
gr. 3
gr. 3-5
gr. 3-5
gr. 3-5
546
DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued)
Drug.
Acid, Tannic {Continued).
Tannigen. (Acetyl-tannin.)
Used as an intestinal astringent ....
Also by rectum : 1 % solution of Tannic
Acid in an enema, for dysentery or col-
itis.
Acid, Tartaric.
Seldom used except as one of its salts.
Potassium Bitartrate. (Cream of Tartar.)
Diuretic, refrigerant, and aperient.
Used as an ingredient of diuretic drinks.
To one pint of water to be drunk in
twenty-four hours, is added :
Potassium and Antimony Tartrate.
(Tartar Emetic.)
Used as an expectorant. Its action
is too violent for use as an emetic.
Best given alone or with Ipecac in a
tablet or in a mixture with a simple
elixir.
May cause severe gastro-enteritis
in too large doses
Potassium and Sodium Tartrate. (Ro-
chelle Salt.)
Laxative
Aconite. (Aconitum Napellus.) (Root
contains 0.5% Aconitin.)
Tincture of Aconite Root (10%).
Used in a beginning fever as a circu-
latory sedative and an analgesic
Alcohol. (Ethyl Alcohol, Spirits of
Wine.)
Best given as Whisky or Brandy for
a general stimulant toward the end of
an illness or as a last resort.
Brandy. (Spiritus Vini Gallici, con-
taining 39-47% alcohol by weight.)
Whisky. (vSpiritus Frumenti, contain-
ing 44-50% alcohol by weight.) . .
Sherry Wine. (Vinum Xerici, contain-
ing Alcohol 15-20% by weight.) . . .
Aloes.
Not advised in the treatment of
children.
Alum.
Not advised in the treatment of
children.
Ammonium.
Ammonium Bromid. See Bromin.
Ammonium Chlorid. (Sal Ammoniac.)
Stimulating expectorant; best given
dissolved in half an ounce of water
6 Months. 18 Months. 3 Years. | 5 Years
gr. 1-2
gr. 15
gt. i
gtt. 5-10
gtt. 5-10
gr. i
gr. 1-2
gr. ik
gr. 30
gt. i
gtt. 10-
20
gtt. 10-
20
gtt. 30
gr.
i-*
gr. 2-3
gr. tU
51-2
gt. 1
gtt. 20-
30
gtt. 20-
30
gtt. 45-
51
gr. 3-5
gr. 1
54
gr. lU
53-4
gtt. 1-2
gtt. 30-
40
gtt. 30-
40
51-2
gr. 1-2
FOR INTERNAL USE 547
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSE— (Continued)
Ammonium {Continued).
Ammonium Carbonate. (Sal Volatile.)
Stimulating expectorant; best given
dissolved in half an ounce of water
Solution of A m m oniu m A cetate. (Liquor
Ammonii Acetatis or Spirits of
Mindererus.)
Stimulating expectorant ; best given
well diluted in carbonic water.
Used also as a diuretic, antipyretic,
and diaphoretic
Aromatic Spirits of Ammonia. (Spiri-
tus Ammonii Aromaticus.)
Used as a stimulating expectorant,
volatile stimulant, carminative, and
antispasmodic. Best given well diluted
with water
Antimony.
Antimony and Potassium Tartrate.
(Tartar Emetic.) See under y4 c/</,
Tartaric.
Antipyrin.
Analgesic and sedative in pertussis
and laryngitis.
Best given alone in powder form, or
with Sodium Bromid in solution
Antitoxin. See Serum, Antidiphther-
itic.
Apomorphin.
Not advised in the treatment of
children.
Arsenic.
Arsenious Acid. (Arsenic Trioxid or
White Arsenic.)
Used in anemia, malaria, and
chorea.
Administered either in solution (see
Fowler's Solution) or in tablets with
other ingredients.
In large doses it is an irritant poison
causing puffiness of the eyes and gas-
tro-enteritis, both of which are signs of
an overdose.
Cannot be given with astringents,
tinctures, or decoctions, or with solu-
tions of Iron.
Antidotes are Hydrated Iron with
Magnesia, egg-albumen, and emetics.
Given three times a day
Fowler's Solution. (Liquor Potassii
Arsenitis.)
Uses, action, and antidotes are the
same as Arsenious Acid.
Best given in water into which it is
freshly dropped
6 Months. 18 Months. 3 Years. 5 Years.
gr. i-i
gtt. 3
gr. i
gr. i-1
oM
gtt. 3-5
1-U
gt. i
gr. 2i<i
gt. 1
gr. 1
31
gtt. 5
gr.
gr-Ti^
gtt. 2
gr. 1-2
52
gtt. 5-10
gr. 3
gr- T¥o
gtt. 2-5
548 DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL HSU— (Continued)
ASAFETIDA.
Emulsion of Asafetida. (Milk of Asa-
fetida.)
Used chiefly as an ingredient of
enemata, especially in excessive tym-
panites. To 8 ounces of diluent
AsPiDiUM. (Male-fern.)
Oleoresin of Male-fern.
Teniafuge.
Best given in emulsion or in cap-
sules
Aspirin. See under Acid, Salicylic.
Atropin. See under Belladonna.
Basham's Mixture. See under Iron.
Belladona. (From the leaves of the
Atropa Belladonna, containing
0.35% of alkaloid.)
Atropin. (Alkaloid of Belladonna.)
Respiratory stimulant, antihidrotic.
Used as a stimulant, a mydriatic,
and for the cure of enuresis
Tincture of Belladonna (10% leaves).
Uses similar to Atropin
Belladonna Leaves. (Asthma Powder.)
Used occasionally with the leaves of
Conium and Stramonium, and Potas-
sium Nitrate (Saltpetre) to relieve at-
tacks of asthma. To be burned in a
metallic receptacle.
Benzoic Acid. See Acid, Benzoic.
Bichlorid of Mercury. See under
Mercury.
Bismuth.
Bismuth Subcarbonate.
Intestinal astringent and sedative. . .
Bismuth Subgallate. (Dermatol.)
Intestinal astringent and sedative.
Used also externally
Bismuth Subnitrate.
Intestinal astringent and sedative . . .
Bismuth Subsalicylate. See under Acid,
Salicylic.
Blaud's Pill. See under Iron.
Borax. (Sodium Borate.) See under
Sodium.
Brandy. See under Alcohol.
Bromin.
Used only in the form of its salts.
Ammonium Bromid.
Sedative. Used in laryngismus,
pertussis, asthmatic bronchitis, and
sleeplessness.
Best given well diluted with water. . .
6 Months. 18 Months. 3 Years. 5 Years.
gt. M
gr. 10
gr. 3-5
gr. 5-10
gr. 1-3
gr. 3^
gt. 1
gr. 10
gr. 5
gr. 10
gr. 2-4
31
gr. 10-
15
gr. T^o
gtt. 1-2
gr. 10
gr. 5-10
gr. 10-
15
gr. 3-5
31
gr. 20-
30
gr. ih
gt. 3-5
gr. 20
gr. 10
gr. 20
gr. 5-8
FOR INTERNAIv USE 549
DRUGS AND DRUG DOSAGE— FOR INTERNAL USE— (Continued)
Drug.
Dose.
6 Months.
18 Months
3 Years.
5 Years.
Bromin (Continued).
Potassium Bromid.
Used same as the Ammonium salt,
but it is more depressing
Sodium Bromid.
gr. 1-3
gr. 2-4
gr. 3-5
gr. 5-8
Used same as the above. It is mid-
way between the Ammonium and the
Potassium salts in its depressant action.
Strontium Bromid.
gr. 1-3
gr. 2-4
gr. 3-5
gr. 5-8
Used same as the above
gr. 1-3
gr. 2-4
gr. 3-5
gr. 5-8
Brown Mixture. See under Liquorice.
Caffein.
Citrate of Caffein (50% Caffein).
General stimulant and diuretic
Calcium.
gr. *
gr. i-1
gr. 1
gr. 1-2
Calcium Chlorid.
Of some benefit in hemophilia and
purpura hemorrhagica
gr. i
gr. 1
gr. 1-2
gr.2
Calcium Sulphid.
Antipustulant
gr. aV
gr. ,V
gr. ,\
/v.. 1
Prepared Chalk.
gr- To
Antacid
gr.2
gr. 3
gr. 5
gr. 5-8
Compound Chalk Mixture. (Mistura
Cretae Composita.)
20% Chalk Powder, 40% Cinnamon-
water.
Antacid. Every 2 hours
T 1
"Z 1
oH
32
Calomel. See under Mercury.
0 1
0 i
Camphor.
Powdered Camphor.
Used in coryza. Every 2 hours
gr. tV
gr. ^
gr. i
gr. i
Spirits of Camphor (10%, in Alcohol).
Stimulant, anodyne, carminative . . .
gtt. 3
gtt. 5
gtt. 5-10
gtt. 10
Water of Camphor. (Aqua Camphorae.)
(Contains 0.8% of Camphor.)
Used as a vehicle.
Cantharides.
Used best in :
Tincture of Cantharides (10%).
Useful in cystitis and functional
albuminuria
gt. i-i
gt. i
Capsicum.
Used best in:
Tincture of Capsicum (10%).
Used as a carminative and stom-
achic. Best given well diluted in
water
(Tf 1
gtt. 2-3
gtt. 3-5
Cardamom.
g"-. i
Used best as :
Tincture of Cardamom.
Used as a carminative
gtt. 5
gtt. 10
gtt. 15
gtt. 20
Cascara Sagrada. (Bark of the Rham-
nus Purshiana.)
Extract of Cascara Sagrada.
(Four times the strength of the bark.)
Tonic laxative
.gr. *
gr. 1-2
gr. 3-5
550 DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— {Continued)
Drug.
Cascara Sagrada {Continued).
Fluidextract of Cascara Sagrada.
(Aromatic.) (1 c.c. = 1 gm. bark.)
The active principles are retained,
but the bitter principles are eliminated.
Tonic laxative
Castor Oil. (Oleum Ricini.)
(Expressed from the seeds of Ricinus
Communis.)
Bland oil and cathartic.
Given usually for one dose
Cerium Oxalate.
Sedative in vomiting
Chalk. See Calcium.
Chloral Hydrate.
Sedative, hypnotic, and antispas-
modic.
Best given in some Inland fluid by
rectum
Chloroform.
Given internally as :
Spirits of Chloroform. (Chloric Ether.)
(6% Chloroform.)
Carminative, antispasmodic, and sed-
ative
Water of Chloroform. (Aqua Chloro-
formi.) (0.5% Chloroform.)
Vehicle and carminative
Cinchona. See under Ouinin.
CocAiN, or:
Cocain Hydrochlorid.
Local anesthetic by hypodermic
injection.
Used in 0.2% to 4% strength. But
seldom used for local anesthesia in
children. Used by the mouth in
obstinate vomiting
CoDEiN. See Opium.
CoD-LivER Oil. (Oleum Morrhuae.)
Fixed oil from fresh cod's hvers.
Alterative and tonic.
Given three times a day
Dose
6 Months. 18 Months. 3 Years. 5 Years,
Corrosive Sublimate. See Corrosive
Chlorid of Mercury.
Cream of Tartar. See under Acid,
Tartaric.
Creosote. (Beechwood Creosote.)
Tonic, alterative, and antitubercu-
lar.
Best given in an emulsion with
Cinnamon-water, three times a day
after meals
gtt. 15
51
gr.2
jtt. 2-3
gtt. 30-
45
52
gr. 2-3
gr. 1
rtt. 3-5
5*-2
gtt. 1
15
gt. *
gr- riiT
gtt. 15-
20
51
gr. 3
gr. li
gtt. 5-55
52-3
gr. ?V
gtt. 20-
30
gtt.
1-2
54
gr. 3-5
gr.2
gtt. 15-
20
54
gr.^
5i-i
gtt. 2-3
gtt. 3-5
FOR INTERNAL USE 551
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSE— (Continued)
Druc
Creosote (Continued) .
Creosotal. (Carbonate of Creosote —
92% Creosote.)
Is preferable to Creosote because
it has little odor, a inore agreeable
taste, and is better borne by the stom-
ach
Dermatol. (Bismuth Subgallate.) See
under Bismuth.
Digitalis. (From the leaves of Digitalis
Purpurea.)
Heart stimulant and tonic; also
diuretic.
Best given by mouth in the form
of the Tincture and hypodermically
either as the Tincture or as Digitalin.
Tincture of Digitalis (10% leaves)
Infusion of Digitalis (66 gm. = 1 gm.
leaves)
Digitalin (ten times strength of leaves).
Diphtheria Antitoxin. See Serum,
A nti-diphtheritic.
Dover's Powder. See under Opium.
Epsom Salt. See under Mae,ucsium.
Ergot. (From the sclerolium of the
Claviceps Purpurea of Rye.)
Hemostatic, heart and circulatory
stimulant.
Fluidextract of Ergot (1 c.c. = l gm.
Ergot)
Eriodyctyon. See Verba Santa.
Ether.
Used internally as :
Compound Spirits of Ether. (Hoff-
mann's Anodyne, 32.5% Ether.)
Anodyne, carminative, antispas-
modic, and stimulant.
Best given well diluted with water. . .
Spirits of Nitrous Ether. (Sweet
Spirit of Niter, 4% Ethyl Nitrite.)
Used as a diaphoretic, diuretic
and carminative.
It is volatile and explosive and
incompatible with many drugs. Best
given alone or in a simple elixir
Fel Bovis. See Ox-gall.
Ferrum. See Iroti.
Fowler's Solution. See Arsenic.
Gallic Acid. See Acid, Gallic.
Gentian.
Extract of Gentian.
Stomachic and bitter tonic.
Given three times a day
Glauber's Salt. (Sodium Sulphate.)
See under Sodium.
Dosii.
Months. 18 Months
gt. ^
gt. h
gr. jh
gtt. 2-3
gtt. 2
gtt. 2-3
gtt. 2
gt. 1
gr. ^U
gtt. 5
gtt. 3-5
gtt. 3-5
Years. 5 Years.
gtt. 2-3
gtt. 3-5
gtt. 1-2 gtt. 2-3
oi-1 151-3
gr. ih gr. jU
gtt. 5-8 gtt. 10-
15
tt. 5 gtt. 5-10
rU. 5
gr. i-i
gtt. 5-10
gr. *-l
552
DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued)
Drug.
Dose.
6 Months.
18 Months.
3 Years.
5 Years.
Glonoin. See Nitroglycerin.
Glycerin.
Used chiefly as a demulcent base
and a vehicle for other drugs.
Glycyrrhiza. See Liquorice.
HexamEThylenamin. Official name for
the proprietary Urotropin, q. v.
Hoffmann's Anodyne. See under Ether.
Hydrargyrum. See Mercury.
Hyoscyamus.
Tincture of Hyoscyamus.
Sedative and antispasmodic.
Given every two hours
gt. ^-1
o^tt 1-2
gtt. 3
gtt. 3-5
Liquor Ferri et Ammonii Acetatis.
j,LL. 1 z.
(Basham's Mixture — Solution of
Iron and Ammonium Acetate — 10%
metallic Iron)
gtt. 15-
ol
gtt. 20-
Ovoferrin. (Proprietary Organic Iron.)
gtt." 5
gtt.' 10
20
30
Pyrophosphate of Iron (10% of metallic
Iron)
gr. 1-2
gr. 2-3
Syrup of the lodid of .Iron (5%, Ferrous
lodid)
gtt. 3
gtt. 6
gtt. 10
gtt. 20-
30
Tincture of the Chlorid of Iron.
(35% of Ferric Chlorid and must be
at least one year old.)
gt. 1
gtt. 3
gtt. 5
gtt. 10-
15
Jalap.
Powdered Jalap. (Contains 8 % Resin . )
Hydragog cathartic and diuretic
gr. 2
gr. 3
Lactic Acid. See Acid, Lactic.
Liquorice.
Compound Liquorice Mixture. (Brown
Mixture^ 12% Paregoric.)
Sedative expectorant mixture.
Given at two-hour intervals
gtt. 15
gtt. 20
gtt. 30-
40
gtt. 40-
51
Compound Liquorice Poivder.
Laxative
gr. 10
gr. 10-
20
gr. 30
gr.40-
31
Magnesium.
Magnesium Carbonate.
Antacid and laxative
gr. 5-10
gr. 20
gr. 30-
gr. 40-
40
31
Magnesium Citrate, Solution of. (Liq-
uor Magnesii Citratis.)
Laxative. For one dose
52
§2-4
Magnesium Oxid. (Calcined Magnesia.)
Antacid and laxative
gr. 5-10
gr. 10-
gr. 20-
gr. 30-
20
30
40
Magnesium Sulphate. (Epsom Salt.)
Laxative. To be given every two
hours and discontinued when the de-
sired effect has been produced
gr. 10-15
gr. 20
gr. 20-30
3*-i
FOR INTERNAL USE 553
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSZ— (Continued)
Drug.
Male-fern. See Aspidium.
Mentha Piperita. See Peppermint.
Mentha Viridis. See Spearmint.
Mercury.
Mass of Mercury. (Blue Mass — 35%
Mercury.)
Cathartic and antisyphilitic.
Used once a day
Corrosive Chlorid of Mercury. (Bichlo-
rid of Mercury or Corrosive Sub-
limate.)
Antisyphilitic.
Given three times a day
Mild Chlorid of Mercury. (Calomel.)
Cathartic, cholagog, antisyphilitic.
At 30-minute intervals
At one-hour intervals
Rarely necessary to give more than
one grain for laxative effect.
Red lodid of Mercury. (Biniodid.)
Antisyphilitic.
Given three times a day
Alercury with Chalk. (Gray Powder.)
(38% Mercury.)
Intestinal antiseptic, cholagog, and
antisyphilitic.
At one-hour intervals — total gr. 1 . . .
At one-hour intervals — total gr. 2 . . .
Methyl Salicylate. See under Acid,
Salicylic.
MinderErus, Spirits of. See under
Ammonium.
MoRPHiN. See under Opium.
Myrrh.
Tincture of Myrrh (20%).
Used as a mouth-wash diluted with
water.
Niter. See under Ether, Sweet Spirits of
Niter.
Nitroglycerin. (Glonoin, Glyceryl Tri-
nitrate.)
Vaso-dilator
Spirits of Glyceryl Trinitrate, or Spirits
of Glonoin, old U. S. P. (1%
alcoholic solution.)
Nux Vomica. (From Strychnos Nux
Vomica.)
Tincture of Nux Vomica (1% Strych-
nin).
Stomachic and stimulant
Strychnin. (Alkaloid of Nux Vomica.)
General stimulant, well borne by
children.
Every two or three hours
Dose.
6 Months. 18 Months. 3 Years. 5 Years.
gr- T(T
gr- xio
gr. 1
gr. T^o
gt.i
gt. ^
gr- i-To-
20T)
gr- jho
gr- i
gr- 1^0
gr i
gr. 3(Jo
gt. i
gt. 1
gr. jh
gr-
gr- lU
gr. i
gr-i
. h
jtt. 1-2
gr- TUo
gr. 1-2
gr- yV
gr.'i
gr.2'W5
gr-i
gr-iio
gt. 1
gtt. 2-4
gr. T50
554 DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL USU— (Continued)
Dose.
Drug
OivEUM Gaultherium. (Oil of Win-
ter-green.) See under Acid, Sal-
icylic.
Oleum Morrhu^. See Cod-liver Oil.
Oleum Oliv.b. See Olive Oil.
Oleum Ricini. See Castor Oil.
Olive Oil.
Laxative and nutrient
Used at night by rectum for the
cure of constipation
Opium.
Sedative, anodyne, hypnotic.
Tincture of Deodorized Opium (10%).
Used in 3- to 10-drop doses in ene-
mata as a sedative for children under
five years of age.
Camphorated Tincture of Opium. (Par-
egoric— 0.4% Opium.)
Sedative and analgesic
Powder of Ipecac and Opium. (Dover's
Powder — 10% each of Ipecac and
Opium.)
Sedative
Morphin. (Alkaloid of Opium.)
Not well borne by children and best
given hypodermatically
Codein. (Methylmorphin.)
As sulphate or phosphate
Heroin. (Diacetylmorphin.)
As hydrochlorid.
Bronchial sedative
Orange-juice. (Citrus Aurantium.)
Antiscorbutic
Ox-gall. (Fel Bovis — Fresh Ox-bile.)
Used as a laxative in enemata —
05- 5 1 to a pint of water.
Paregoric. Camphorated Tincture of
Opium. See under Opium.
PEPo. See Pumpkin Seed.
Peppermint.
Aqiia Mentha Piperitce — Peppermint
Water. (0.2% Oil of Pepper-
mint.)
Carminative, sedative, corrective and
vehicle
Pepsin.
Powdered Pepsin
Essence of Pepsin
Phenacetin. (Acetphenetidin.)
Antipyretic and analgesic
Phosphoric Acid. See Acid, Phos-
phoric.
6 Months. 18 Months.! 3 Years.
gtt. 15
ol
gtt. 3-5
gr. i-i
gr. ik
5i
51
gr. 1
gtt. 20
gr. ^
gtt. 15-
30
gtt. 10
gr. i-l
gr- T^o
gr. 2V
51-2
gr. 1-2
gtt. 30-
40
gr. 1
gtt. 30-
51
52
gtt. 15-
20
gr. 1-U
gr. io
gr. tV
gr. -io
53
gr. 2-3
gtt. 40-
51
gr. U
gtt. 20-
30
gr. 2-3
gr. is
gr.i
gr. io
ol
54
gr. 3
51
gr. 2
FOR INTERNAI. USE 555
DRUGS AND DRUG DOSAGE— FOR INTERNAL USE— (Continued)
Dose.
Drug.
Phosphorus.
Oleum Phosphoratum ( 1 % in Almond Oil)
Alterative gt. i
Syrup of Hypo phosphites.
(Calcium' 4.5%, Sodium and Potas
slum each 1.5%.) 5i
PiLOCARPIN.
Not advised in the treatment of
children.
Potassium.
Potassium Acetate.
Diuretic, refrigerant, and alterative. . gr. 1-2
Potassium Bicarbonate.
Should not be given to children on
account of its disagreeable taste.
Potassium Bitartrate. (Cream of Tar-
tar.) See under Acid, Tartaric.
Potassium Bromid. See under Bromin.
Potassium Citrate.
Diaphoretic and diuretic.
Used in acute bronchitis gr. ^-
Potassium Chlorate.
Astringent and antisialogog.
Used in stomatitis of every type
in tonsillitis and angina gr.
Potassium lodid.
Antispasmodic and antisyphihtic . . gr.
Potassium and Sodium Tartrate.
(Rochelle Salt.) See under Acid,
Tartaric.
Prunus ViRGiNiANA. See Wild Cherry.
Pumpkin Seed. Pepo.
Teniafuge. Best given in an emul-
sion ; average dose 5 1 ■
Quassia.
Infusion of Quassia.
Vermifuge.
An extemporaneous infusion is made
by adding 1 or 2 oz. of Quassia chips
to a pint of water. This is injected
high up into the bowel.
Used particularly to destroy the
Oxyuris vermicularis.
QuiNiN. (Alkaloid of Cinchona.)
Bisulphatc of Onimn i gr
Sulphate of Oiiiiiin gr
Tincture of Cinchona
6 Months. 18 Months. 3 Years. 5 Years,
All these are bitter tonics and
antiperiodics.
Rhamnus Purshiana. See Cascara Sa-
grada.
Rhubarb.
Powdered Rhubarb.
Laxative
gt. 1
31
gr.
2-3
gtt. li
31
gr. 3
gr. 1-2
gr. 1-2
gr. 1-2
gr.
2-3
2-3
gr. 1-
gr. 1-
gtt. 5-10
gr. 2-3
gr. 2-3
gr. 2-3
gtt. 15
gtt. 2-4
31-2
gr. 5
gr. 4
gr.3
gr. 3
gr. 3-4
gr. 3-4
gtt. 20-
30
556 DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL USH— (Continued)
Rhubarb {Continued).
Aromatic Syrup of Rhubarb.
Laxative and flavoring medium . . . . ,
Mixture of Rhubarb and Soda.
Corrective and laxative.
I^. Pulveris rhei
Sodii bicarbonatis aa gr. 48
Syrupi rhei aromatici o 1
AquEe q. s. ad o2
M.
Sig. — One to three doses daily
RocHELLE Salt. See under Acid, Tar-
taric.
Saccharin. (Benzosulphinidum.)
Substitute for sugar, but 200 times
sweeter.
For 8 oz. of food, ^-1 grain is suffi-
cient.
Saccharose. See Sugar.
Salicylic Acid. See Acid, Salicylic.
Salol. See under Acid, Salicylic.
Santonin. (Anhydrid of Santoninic
Acid.)
Vermifuge, for round-worms partic-
ularly
Senna.
Cathartic. Best given as Compound
Liquorice Powder, of which it is an
ingredient, q. v.
Serum AntidiphTheriticum. (Diph-
theria Antitoxin.)
For immunization:
1000 to 2000 units.
In faucial diphtheria:
3000 to 5000 units and repeat in
8 hours if required.
In laryngeal diphtheria :
5000 units and repeat in 8 hours if
required.
The repetition of the doses of
Antitoxin is discontinued only
when the case ceases to require the
serum.
The dosage is independent of the
age of the patient.
SODIU.M.
Sodium Benzoate.
Antiseptic, antipyretic, and anti-
rheumatic.
Used in cystitis with alkaline fermen-
tation to acidifv the urine, which it
does by the hberation of hippuric
acid
Sodium Bicarbonate.
Antacid, antirheumatic
Months. 18 Months.! 3 Years. 5 Years.
51
oi
gr. i
gr. 1
gr. 1-2
52
52
gr. 1
gr. 1-2
gr. 2
53
53
gr. 1-2
gr. 2
gr. 3
34
54
gr. 2
gr. 3
gr. 5
FOR INTERNAL USE 557
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSB— (Continued)
Sodium (Continued).
Sodium Borate. (Borax.)
Antiseptic and astringent.
Used as a gargle and mouth-wash
in angina and stomatitis — ol to 58
of water.
Sodium Broynid. See under Bromm.
Sodium lodid.
Uses and doses the same as Potas-
sium lodid, q.v.
Sodium Phosphate.
Laxative and cholagog
Sodium Sulphate. (Glauber's Salt.)
Cathartic.
Used in intestinal infection of mac-
tive type
18 Months. 3 Years.
gr
5-10
Sodium Salicylate. See under Acid,
Salicylic.
Spearmint. (Mentha Viridis.)
Water of Spearmint. (Aqua Menthae
Viridis— 0.2% Oil of Spearmint.)
Carminative, sedative, corrective,
and vehicle
Strontium.
Strontium Bromid. See under Bromm.
Strophanthus. .
Tincture of Strophanthus (11% m New
Pharmacopeia, or twice former
strength).
Cardiac tonic and dmretic. Pre-
ferred to Digitalis in the treatment of
children because better borne.
Strychnin. See under Nux Vomica.
Sugar. (Cane-sugar or Saccharose.) _
Sweetening agent. May be substi-
tuted for Lactose in the adaptation
of cow's milk for infant-feeding.
I level tablespoonful equals i oz.
Sugar of Milk. (Lactose.)
Used as an excipient and in the
adaptation of cow's milk for infant-
feeding.
1 level tablespoonful equals J oz.
Sulphonal.
Not advised in the treatment of
children.
Sulphur.
Precipitated Sulphur, or Milk of Sul-
phur.
Laxative and alterative. Given usu-
ally in syrups or other heavy vehicles. .
Used also as a reducing agent in
Bismuth mixtures when the stools do
not become dark colored (see p. 201)
gr. 15-
30
51
gr. 10-15
gr. 30-
45
52
gr. 15-20
gr. 40-
51
53
gt. 1
gr. 20-30
51
54
gtt. 1-2
gr.
gr-
gr
5-10
gtt. 2
gtt. 2-3
gr.
15-30
gr. 1
gr.
51
gr. 1
558 DRUGS AND DRUG DOSAGE
DRUGS AND DRUG DOSAGE— FOR INTERNAL VSU— (Continued)
Dose.
6 Months.
18 Months.
3 Years.
5 Years.
Tannalbin. See under Acid, Tannic.
Tannigen. See under Acid, Tannic.
Tartar Emetic. See under Acid, Tar-
taric.
Tartaric Acid. See Acid, Tartaric.
Terebene.
Stimulating expectorant and anti-
septic. . .
gt. 1
gtt. 1-2
gtt. 2
Terpin Hydrate.
Expectorant and antiseptic.
Used in subacute and chronic bron-
chitis
gr. i
gr.*
Trional.
Not advised in the treatment of
children. ♦
Urotropin. (Trade name for Hexame-
thylenamine.)
Urinary antiseptic and sedative
gr.i
gr. 1
gr. 1-2
gr. 2-5
Whisky. See under Alcohol.
AViLD Cherry.
Syrup of Wild Cherry. (Syrupus
Pruni Virginiani.)
Bronchial sedative and vehicle.
oi
31
DRUGS FOR EXTERNAL USE
Acid, Boric.
Antiseptic of mild grade. 4% is a saturated solution.
Used both in solution and in ointments.
In the form of scales it is most soluble and most convenient.
Acid, Carbolic See Phenol.
Acid, Chromic (Chromic Trioxid.)
A very strong caustic and astringent, used as a substitute for Nitrate
of Silver.
Acid, Nitric (68% pure acid).
Used as a caustic.
Acid, S.^licylic
Used in lotions or in ointments, 1% to 3%, for skin affections.
Acid, Tannic
Astringent.
Used in 1% solution in dysentery; as an ingredient of suppositories for
hemorrhoids. See also Glycerite of Tannin under Glycerin.
Adrenalin. (Trade name for the active principle of the Adrenal Gland.)
Used in a solution in the strength of 1 part to 1000 of normal saline solution
or sterilized oil.
Local hemostatic and astringent. It will render bloodless the field of opera-
tion of the eye, nose, and throat, but its use is often followed by hemorrhage.
Aluminium Acetate, Solution of.
Antiseptic dressing for cellulitis, abscesses, etc.
1. I^. Aluminii sulphatis oSj
Acidi acetici o4J
Aqu£e o 10
2. I^. Calcii carbonatis o H
Aqufe 5 2|
Add 1 to 2, stirring.
DRUGS FOR EXTERNAL USE 559
Amylum. See Starch.
Argentum. See Silver.
Argyrol. See Silver.
Aristol. (Thymol Di-iodid.)
Mild antiseptic, used as a dusting-powder or in ointments.
Balsam of Peru.
A stimulating dressing for wounds and ulcers.
In Castor Oil, one part of the Balsam to six of the oil, it makes a useful
application for Ijurns and wounds.
Benzoin.
Compound Tincture of Benzoin.
Used as a bronchial sedative in steam inhalations, one-half ounce to
two pints of water.
BiCHLORiD OF Mercury. See under Mercury.
Bismuth Subg.^llate. (Dermatol.)
Used externally as a drying antiseptic powder, either pure or in com-
bination. Also as an ingredient of ointments of 10% to 20% strength.
Boracic Acid. See Acid, Boric.
Cacao-butter. (Oleum Theobromatis.)
A fixed oil expressed from the seeds of the Theobroma Cacao. Melts
at 30°-35° C. (86°-95° F.).
Used as an emollient and as a base for suppositories. It may be used
for nutrient inunctions, but it is less effective than Goose Oil.
Calamine. (Zinc Carbonate.)
Used as an ingredient of soothing lotions in itching affections of the
skin — eczema, urticaria, dermatitis venenata, etc.
Calomel. See under Mercury.
Cantharides.
Vesicant. Used best in the form of Collodion of Cantharides, q. v.
C.\RRON Oil. (Limentum Calcis.)
Consists of equal parts of Lime-water and Linseed Oil.
Used as a soothing application for burns and scalds.
Chloroform.
Locally a rubefacient and, when confined, a vesicant as well. A useful
ingredient of liniments.
By inhalation, a general anesthetic.
Chrysarobin.
LTsed in 5% ointment for psoriasis and tinea tonsurans.
COCAIN.
Alkaloid obtained from several varieties of Coca.
A local anesthetic when applied to wounds or mucous surfaces or when
injected hypodermically.
For local application, 3% to 10% solutions.
For hypodermic use, 0.2% to 4% solutions.
CoD-LivER Oil.
May be used locally as a nutrient inunction, but its odor is objection-
able.
Collodion.
Solution of Pyroxylin in Alcohol and Ether.
Collodion of Cantharides (60% Cantharides). An excellent blistering^
agent.
Collodion of Ichthyol (10%,-20%). Used to cover the wound after aspir-
ations or lumbar punctures, and in checking the spread of erysipelas.
Collodion of Iodoform (5%). Used in erysipelas.
Collodion of Oil of Cade (l%-5%). Used in eczema.
Collodion of Salicylic Acid (10%). Used in removing corns and callouses.
Creosote.
Used in inhalations as a pulmonary antiseptic.
Dermatol. See Bismuth Subgallate.
Eucain.
Beta-eucain. Local anesthetic with similar action and uses to Cocain,
but without its toxicity. Its solutions can be sterilized without injury
by boiling.
500 DRUGS AND DRUG DOSAGE
FORMALDEHYD.
Antiseptic and deodorant.
Used in solutions of from 0.5% to 2% strength, as an antiseptic.
Used in the form of the gas for disinfecting, the gas being generated
by heat, from solutions, or from the solid, Paraform.
Glycerin.
Used chiefly as a solvent or excipient. Very hygroscopic. It is the
base of the Glycerites.
Glycerite of Carbolic Acid — 20% Phenol in Glycerin. An external anti-
septic and antipruritic.
Glycerite of Starch — 10%. A vehicle for skin preparations and for pills.
Goose Oil.
The oil tried from the goose. An excellent oil for nutrient inunctions.
It is better than Olive Oil or Cacao-butter, for being an animal oil it is
more readily absorbed by the skin. It is semifluid, has a low melting-
point, and does not become hard after having been rubbed in.
Grindelia Robusta.
The fluidextract, in the strength of one dram to a pint of water, is used
as a wet dressing in dermatitis venenata.
GUAIACOL.
Combined with equal parts of Glycerin, it is used in acute joint affec-
tions, for its analgesic effect.
HamamELIS. See Witch-hazel.
Hydrargyrum. See Mercury.
Hydrogen Peroxid.
Antiseptic and deodorizer. Used in 10-volume, 3% solution to clean
wounds, and to dissolve and destroy pus.
ICHTHYOL.
Used in 1% solution in intertrigo.
Used in 5% to 50% solutions in skin diseases or in erysipelas.
Used in 5% to 50% ointments in skin diseases or in erysipelas.
Used suspended in oil in strength of 5% to 25% as a nasal spray.
Iodin.
Tincture of Iodin (7%).
Antiseptic and counter-irritant.
Used particularly in tinea tonsurans and tinea circinata.
Iodoform. Formyl Tri-iodid.
Antiseptic and alterative.
Used in the form of a powder, an ointment, or on gauze in the strength
of5%o to 10%.
Kaolin.
Cataplasma Kaolini.
A smooth homogeneous mass consisting of Kaolin, Boric Acid, Thymol,
Methyl Salicylate, Oil of Peppermint, and Glycerin.
Lanolin.
Used as an ointment base.
Lead and Opium Wash.
Anodyne lotion.
I^. Liquoris plumbi subacetatis oiv
Tincturae opii oj
Aquae oxvj
Fiat mistura.
Sig.- — Use externally.
Menthol. (Peppermint Camphor.)
Sedative, analgesic, refrigerant, and antipruritic.
Used in ointments, 1% to 5%.
Used in oily solutions, 1%, to 5%,.
Used triturated with equal parts of Camphor as an anodyne.
Mercury.
Bichlorid of Mercury.
Antiseptic. Used in 1:1000 to 1:20,000 solutions.
Calomel.
A milder antiseptic than the foregoing. Used as a dusting-powder in
eye affections and in the lesions of secondary syphilis.
DRUGS FOR EXTERNAL USE 561
Mercury and Ammonium Chlorid. (White Precipitate.)
Used in ointments of 1% to 10% strength as an antiparasitic and anti-
syphiUtic. Of particular value in impetigo contagiosa, ringworm, etc.
Yelloxv Oxid of Mercury.
Antiseptic. Used in ointments of 0.5% to 10% strength in ophthalmia.
Of value also in ringworm and syphilitic eruptions.
Mustard.
Counter-irritant.
In the form of papers (charta;) for local pain or vomiting.
In the form of powder:
In pastes of a strength of 1 part of mustard to from 2 to 6 parts of flour.
In baths — 1 tablespoonful to 6 gallons of water.
In packs, in the same proportion.
Oil of Cade. (Oil of Juniper Tar.)
Used as an antiparasitic in skin diseases.
In powders, 1% to 5% in a base of Stearate of Zinc.
In ointments, 1% to 5%.
In Collodion, 1% to 5%.
Oil of Turpentine. (Spirits of Turpentine.)
Rubefacient and counter-irritant.
Used as an ingredient of liniments.
Used in the form of turpentine stupes for the relief of abdominal distention.
Flannel cloths are wrung out in hot water to each pint of which gtt. 10-20 of
Oil of Turpentine have been added, and are then applied to the abdomen.
OuvE Oil.
Used externally as a nutrient inunction.
Petrolatum (Petroleum Jelly or "Vaselin").
Used as a base for ointments.
Phenol. (Pharmacopeial name of Carbolic Acid.)
Local anesthetic and antiseptic.
Used as an antiseptic in solutions of the strength of 5% or less.
Used as a caustic and local anesthetic in strength of 95%.
Children are very susceptible to Phenol poisoning.
Pix Liquida. See Tar.
Potassium Permanganate.
Antiseptic and disinfectant.
Used in solutions in the strength of 1 : 4000 to 1 : 2000 on mucous sur-
faces, and in the strength of 1 : 1000 on ulcers and superficial wounds.
Resorcin.
Antiseptic in skin diseases, particularly in seborrheic eczema.
Lotions, 1% to 5%.
Ointments, 1% to 5%.
Silver.
Silver Nitrate. Antiseptic and astringent. Used in solutions of 1% to
50% strength. As a caustic, it is used in the solid form.
Argyrol. (Silver Vitellin — Proprietary.)
A mild antiseptic, not approaching the Nitrate in efhcacy. Used in
solutions of 5% to 50% strength or in ointments of 5% to 50% strength.
Sodium Bicarbonate.
Used in saturated solution as an antipruritic and as an analgesic in skin
diseases and burns.
Starch.
Used as the base of drying-powders.
Sulphur.
In 5% to 55% ointments as a parasiticide, particularly in scabies.
Tar. (Pix Liquida.)
Antiseptic. Used in skin diseases as the officinal ointment (50%) or
in ointments with other ingredients.
Zinc Oxid.
Used as a 20% ointment in Benzoinated Lard, in skin diseases, such
as eczema, needing a mild astringent.
Used in dusting-powders in the strength of 5% to 10%.
Official Zinc Ointment makes a good base for stronger antiseptics, such
as Tar and Oil of Cade.
.^,6
INDEX
Abdominal distention as sign of peri-
tonitis, 469
in chronic ileocolitis, 204
in inactive enteric infection, 197
massage in constipation, 175
Abscess, ischiorectal, 218
of breast, 53
peritonsillar, incision of, 240
situations of, 240
treatment of, 241
retropharyngeal, 244
breathing in, 244
examination of throat in, 244
incision of, 244
position of head in, 244
treatment of dysphagia in, 244
Absorption of saline solution in colon
irrigation, 209
Acarus scabiei, 412
Acetone, absence of, in glycosuria,
350
Aconite, tincture of, in fever, 476
in nephritis, 345
in pericarditis, 289
in pleurisy, 279
Adams' position, 522
Adapted milk, 94
Adenitis, acute, treatment of, 424, 425
cervical, confused with mumps, 334
in diphtheria, 302
in scarlet fever, 319
persistent, 425
retropharyngeal, 115, 429
suppurative, 242
tubercular, treatment of, 430
Adenoids, 426
as cause of cough, 254, 324
of incontinence of urine, 338
of laryngeal croup, 246
of nasal catarrh, 232
of nasal hemorrhage, 234
of otitis, 418
of persistent deafness? 422
associated with asthma, 263
cough of, 426
crushing of, 427
deterrent to growth, 143
in chronic otitis media, 422
in epileptics, 372
in laryngismus stridulus, 251
in night-terrors, 363
mouth-breathing due to, 426
Adenoids, occurrence of, 426
operation for, 427
removal of, for chronic bronchitis,
261
return of, after operation, 429
treatment of, 427
without mouth breathing, 232
Adherent pleura as cause of persis-
tent cough, 255, 256
Adhesive plaster strapping in pleu-
risy, 278
in umbilical hernia, 396
in ventral hernia, 397
Adirondacks, good for older children,
501
Adrenalin in hemorrhagic diseases of
the newly born, 54 ^
in nasal hemorrhage, 224
Afternoon nap, 27, 28
Air-cushion in decubitus, 413
Airing nursery and sleeping-room, 58
Air-space necessary in nursery, 24
Albolene inunctions in measles, 331
in rhinitis, 230
spray in scarlet fever, 318
Albuminuria, 342
clothing in a case of, 343
cyclic, 342
diet in a case of, 343
dietetic, 342
examination of urine in, 343
febrile, 342
laxatives in, 343
management of cases, 343
paroxysmal, 342
transient, 342
Albumin-water, formula for preparing,
123
Alcohol, abuse of, 299
administration of, 503
by rectum, hypodermatically, etc.,
498
and mother's milk, 70
and water, bath of, 30
for sponging, 480
in noma, 225
as cause of cerebral palsy, 383
of delicate children, 149
of multiple neuritis, 381
as drug, not a beverage, 497
as food during illness, 133
as galactagogue, 108
563
564
INDEX
Alcohol for nipples, 224
habit easily acquired in chronic
ileocolitis, 205
in bronchopneumonia, 270, 271
in collapse, 498
in diphtheria, 310
in gastro-intestinal infection, 191
in lobar pneumonia, 277
in neurotic children, 363
in prevention of decubitus, 413
in purpura, 450
in scarlet fever, 318
in severe toxemia, 497
in typhoid fever, 461
in vomiting, 192
irritant to the kidneys, 497
narcosis, gavage in, 137
physiologic action, 497
to increase fat in breast-milk, 167
tolerance for, 497
used harmfuUy, 19
when to give, 497
Alderney cream, 107
Alkalies in the adaptation of cow's
milk proteid, 95
Aloes, tincture of, in finger sucking,
432
Alternating use of drugs in cystitis,
352
Alum in pertussis, 325
Ammonium salts, administration of,
503
for children, 269
in bronchitis, 260
in lobar pneumonia, 277
interfering with digestion, 19
unpalatable, 503
Anemias of infancy, 438
bathing in, 438
country hving in, 438
fresh air in, 438
in cardiac disease, 298
intestinal toxemia a cause of, 438
lack of appetite a cause of, 125
Anesthetics, gas-ether sequence, 495
in children, 494
use of, in thoracotomy, 282
Angina, recurrent, 233
associated with cardiac disease,
296
Angioneurotic edema, 387
Antacids in milk adaptation, 95
Anterior poliomyelitis, 378
exercises for, 541
Antipyretic drugs for fever, 476
in lobar pneumonia, 275
in tvphoid fever, 459
Antipyrin, 264
as an antipyretic, 477
as cause of purpura, 449
of urticaria, 407
in catarrhal laryngitis, 250
in laryngismus, 252
Antipyrin in nasal hemorrhage, 234
with sodium bromid in pertussis, 327
Antirheumatic treatment in peliosis
rheumatica, 468
in tonsillitis, 239
Antispasmodic treatment in catarrhal
croup, 248, 249
Antitetanic serum, 54
Antitoxin, diphtheritic, 302
administration of, 302, 304
amount necessary, 303, 304
as cause of urticaria, 409
dosage for immunization, 308
for laryngeal diphtheria, 303
effect on blood, 307
in cervical adenitis, 425
in doubtful cases of diphtheria,
237
in laryngeal diphtheria, 314
in nasal catarrh, 233
in rhinitis, chronic, 233
in suspicious throats, 238
late in diphtheria, 306
repetition of, 304
site of injection, 308
when and how to use, 303
rash, percentage of occurrence, 307
Anus, inflammation of, 213
prolapse of, 216
! Aortic disease, conduct of life in, 297
Aphtha-, Bednar's, 225
Appendicitis, 210, 211
Appetite, habitual loss of, 125
poor, due to fissures of lips, 226
to too frequent feeding, 125
Apple, baked, when allowed, 130
raw, when allowed, 131
for constipation, 163
sauce, when allowed, 130
scraped, in constipation, 172
Aristol collodion for lumbar punc-
ture holes, 374
to cover needle holes, 356
Arizona in tuberculosis, 501
Arnold steam atomizer, 328
sterilizer. 1 1 1
Arsenic as cause of urticaria, 407
in cardiac disease, 298
in chlorosis, 441
in chorea, 369
in diabetes, 351
in habit spasm, 371
in hysteria, 362
schedule in chorea, 369
signs of overdose, 370
Arsenical multiple neuritis, 381
Arthritis in scarlatina, 327
Artificial feeding, 80-98
respiration in asphyxia of newly
born, 48
Dew's method, 48
Laborde's method, 48
Schultze's method, 48
INDEX
565
Ascaris lumbricoides, 214
Asparagus, when allowed, 130
Asphyxia in the newly born, 48
Asphyxiation from nitrous oxid, 495
Aspidium, oleoresin of, in tape-worm,
216
Aspiration of carbolic acid into
larynx, 253
of hydrocele, 356
of pericardium, 290
Aspirin in chorea, 368
in cyclic vomiting, 473
in endocarditis, 292
in habit spasm, 371
in pericarditis, 290
in recurrent bronchitis, 262
in rheumatism, 467
Asthma associated with cardiac dis-
ease, 296
bicarbonate of soda in, 266
bowel function in, 266
drugs in, 264-266
due to irritation by pollen of plants,
263
to Hthemic diathesis, 267
to rheumatism, 465
in recurrent bronchitis, 263
inhalations in, 265
red meat in, 266
rheumatic inheritance in, 263
salicylate of soda in, 266
Astringents in diarrhea, 194
Ataxia, congenital, exercises fo^, 526
Atelectasis, 51
death from, 51
due to compression of fluid, 51
Athrepsia. See Marasmus.
Atlantic City after grippe, 454
for convalescents, 500
Atropin in incontinence of urine, 340
in night sweats, 287
with morphin, 192
Axillary temperature, 475
Babcock milk test, 107
Baby, basket, 19
clothes, 20
condition of, best guide to wet-nurse,
74
Babies' Hospital Dispensary, percent-
age of normal development in
children, 56
rules for feeding children, 92
Bacillus, Klebs-Loffler, causing chronic
nasal discharge, 232
diphtheria, 302, 303
Backward children, often deaf, 422
with adenoids, etc., 422
Bacterial examination for diphtheria,
303
of vaginal discharge before dis-
charge of patient, 358
Baked flours, 119
Balanitis, treatment of, 354
Balsam of Peru for sluggish granula-
tions, 218
Barley gruel, when allowed, 129
jelly, formula for preparing, 123
water after gastro-intestinal infec-
tion, 192
before nursing, 70
in acute ileocolitis, 200
in diarrhea, 161
formula? for preparing, 123
Basket for baby's toilet, 19
for early exercise, 25
Bassorin paste in eczema, 402
Bathing, 58
after meals, 30
of delicate children, 148
in ihness, 58
necessity of daily, 146
of premature infant, 45
Bath-room, temperature of, 29, 483
Baths, alternate hot and cold, 252
and meals, 30
brine, 31
cool, 29
during illness, 483
hot, 31
in anemia, 439
in chronic diffuse nephritis, 348
in furunculosis, 412
in lobar pneumonia, 275
in typhoid fever, 456
mustard, 30
overcoming fear of, 29
reaction after, 30
soda, 31
starch, 31
temperature, for fever, 30
for one year old, 29
for very young, 29
time for daily, 30
tub, 29, 30
varieties, basin, 30
bran, 31
Beans, dried, in dietary of delicate
children, 145
Bed -clothing, care of, in quarantine,
304
Bednar's aphthae, 225
Bed-sores, 413
Bed-time, 43
Bed-wetting. See Incontinence of urine.
Beef broth, formula for preparing,
123
foods, 119
juice, formula for prepanng, 123
in marasmus, 156
scraped, formula for preparing, 123
Beer after sixth year, 132
Belladonna, extract of, 66
in constipation, 164
in epilepsy, 373
566
INDEX
Belladonna, extract of, in pertussis,
326
in rhinitis, 229
Bicarbonate of soda in asthma, 266
in bath, 31
in bronchitis, recurrent, 261, 262
in cardiac disease, 296
in chorea, 368
in cyclic vomiting, 473
in eczema, 402, 403
in intertrigo, 404
in persistent vomiting, 178
in quinsy, 241
in rheumatism, 464
Bichlorid bath after quarantine, 302
of mercury, administration of, 503
an irritant drug, 503
as an ear irrigation, 421
as a wet dressing, 49
for thread-worms, 216
in anemia, 440
in balanitis, 354
in congenital syphilis, 288-290
in mastitis of young girls, 52
in noma, 225
in paraphimosis, 354
in otitis media, chronic, 422
in ringworm of the scalp, 414-416
in tardy malnutrition of syphil-
itic origin, 393
in tetanus, 54
in typhoid excreta, 457
Biedert, quoted, 322
Binder for breasts, 78
Bird's eye diapering, 20
Bismuth mixture, 194
subnitrate, impure, poisoning from,
194
in diarrhea, 194
of scarlet fever, 459
in dilatation of the stomach, 184
in ileocolitis, 201
with Dover's powder in fecal in-
continence, 219
Biting finger-nails, 432
Bladder, irrigation of, in cystitis, 352
non-development of, due to incon-
tinence, 338
stone in, 351
weakness of sphincter of, in enure-
sis, 338
Bleeding from breast causing hema-
temesis, 182
Blindness, transitory, in pertussis, 323
Blisters to spine in poliomyelitis, 379
Blood-streaked stool due to fissure of
anus, 213
Boarding-schools for the cure of hys-
teria, 361
Body-heat, maintenance of, in prema-
ture infants, 45
Boiled milk a cause of constipation,
171
Boils, 411
Bone, dead, a cause of chronic ear dis-
charge, 423
tuberculous disease of, 471
Borax water for nipples, 23
for rectal irrigation in worms, 216
Boric acid in dusting-powder, 52
insufflations in pertussis, 324
ointment, 10 per cent, in cold
cream, 333
in contagious impetigo, 408
in fissure of lips, 220
in furunculosis, 412
in ivy poisoning, 411
in mammary abscess of infants,
53
in vaccination wounds, 486
saturated solution of, 78
in Bednar's aphthae, 226
in care of nipples, 73
in cleansing teeth, 35
in gonorrheal vaginitis, 358
in measles, 331
in noma, 225
in retropharyngeal adenitis,
430
in tonsillitis, 238
mouth-wash of, 49
wet dressing of, 49
for vaccination ulcers,
485
Bottle-fed, constipation in, 169
Bottle-feeding in breast-fed, 70
Bowel function, 166
defective, a cause of colic, 165
in asthmatics, 266
in epilepsy, 372
in lobar pneumonia, 274
in nephritis, 344
in scarlet fever, 316
in tubercular peritonitis, 469
of intestinal intoxication, 166
treatment of, 166
Bow-legs, rachitic, 444
Boys, hysteria in, 360
Braces after poliomyelitis, 379
for bow-legs, 444
for masturbation, 436
to prevent contractures, 384
Brachial plexus, injury to, during labor,
386
Brain lesion as cause of early convul-
sions, 363
Bran bath in eczema, 403
in prickly heat, 416
Brandy, 50, 191, 277, 497. See also
Alcohol.
Breast, abscess of, in newly born, 57
in infants, 53
bandaging, during weaning, 71
binder for, 78, 79
caking of, 78
care of, during weaning, 71
INDEX
567
Breast feeding in marantic infants, 152
massage of, 78
milk by gavage, 137
in chronic ileocolitis, 205
regulation of percentages in, 69, 70
time of appearance of, 72
pump, 78
Breath of diphtheritic patient, 302
Breathing, exercises for, 513-516
Breck feeder in premature infants, 47
Brine baths, 31, 138
for neurotic children, 362
in rickets, 443
in tardy malnutrition, 159
in tetany, 367
with goose oil rub, 443
Bromid of soda, 250, 264
in anterior poHomyelitis, 378
in convulsions, 364
in cough after intubation, 313
in endocarditis, 291
in epilepsy, 372
in gyro-spasm, 366
in hiccough, 387
in hysteria, 363
in laryngismus, 252
in measles-cough, 332
in meningitis, 375
in nephritis, 347
in neuritis, 382
in night-terrors, 365
in persistent hematemesis, 185
in pertussis, 326
in polyuria, 350
in tetanus neonatorum, 54
in tetany, 367
Bromoform in pertussis, 325
Bronchiectasis, interstitial, 287
Bronchitis as complication of influenza, j
453
associated with bronchopneumonia,
257
with measles, 257
with whooping-cough, 257
duration of, 258
fever range in, 257
mustard paste in, 493
physical signs in, 257
predisposing to bronchopneumonia,
267
recurrent, due to rheumatic habit, 463
respirations in, 258
signs of developing bronchopneu-
monia in, 257
svmptoms of, 257
treatment of, 258-261
varieties, 257
Bronchopneumonia. See Pneumonia,
broncho-.
Broths after diarrhea, 194
formulae for preparing beef, chicken,
and mutton broth, 123
in ileocolitis, 201
Broths in illness, 133
in nephritis, 344
nutriment of animal, 310
when allowed, 129
Buckwheat as cause of urticaria, 407
Bullae of skin in pemphigus, 409
Bunge, quoted, 439
Butter in milk idiosyncrasy, 1 1 1
to replace the fat of milk, 146
wlien allowed, 130
Button for umbilical hernia, 396
Cacao-butter rub, 139
CalTein in bronchopneumonia, 270
in fever, 477
in influenza, 452
Caking of breasts, 78
California, for nephritis cases, 500
Calomel and rhubarb in pharyngitis,
236
contraindicated, in the cure of con-
stipation, 173
fumigations in catarrhal croup, 250
in chronic eczema, 404
in gastric indigestion, 178
in ileocolitis, 201
chronic, 206
in influenza, 452
in lobar pneumonia, 274
in pleurisy, 279
in tonsillitis, 238
initial dose, in acute gastro-intestinal
infection, 192
vs. castor oil in acute gastro-intesti-
nal infection, 192
Camphor as a counterirritant, 493
as a heart stimulant, 277
in hemorrhoids, 218
in rhinitis, 231
water in earache, 418
Camphorated oil in mumps, 334
Cancrum oris, treatment of, 224
Candy in chorea, 368
Canine teeth, time of appearance of, 35
Cantharides, tincture of, 342
Capsicum as a counterirritant, 493
Capsules for unpalatable drugs, 504
Carbohydrates, action of, on flora of
intestine, 120
essential ingredients of, 59
function of, as foods, 60
in diarrhea, 161
where found, 59
Carbolic acid in post-antitoxin urti-
caria, 307
in ringworm of the scalp, 414
solution of, for bed-clothes, 301
Cardiac disease, prognosis in, 297
Care of bottles to prevent sprue, 224
of breasts to prevent sprue, 223
of milk on farm, 190
of mouth to prevent sprue, 224
568
INDEX
Cascara sagrada, 66, 206
in cardiac disease, 298
in colic, 166
in constipation, 164, 173, 170
in hysteria, 362
in scarlet fever, 316
Casein, 60, 99
causing constipation, 169. See also
Milk.
cow's, of case records, 39
Cases, illustrative, of abundant but too
weak milk, 69
of adenoids as a cause of persis-
tent cough, 256
of adherent pleura as a cause of
persistent cough, 256
of angioneurotic edema, 357
of antipyretics in typhoid fever,
459
of bed wetting, 339
of cerebral hemorrhage and palsy,
384
of chronic ileocolitis, 205
of colon flushing, 496
of cow's milk idiosyncrasy, 110
of day terrors of intestinal origin,
163
of death from pericranial hemor-
rhage in the newly born, 54
of double empyema, 284
of dysarthria from intestinal toxe-
mia, 163
of eczema, 402
of empyema after bronchopneu-
monia, 283
of empyema necessitatis, 284
of epilepsy, 373
of erythema nodosum, 410
of excessive feeding, 157
of fatal grippe, 453
laryngismus stridulus, 251
of fatigue fever, 478
of fecal impaction, 210
of fissure of the anus, 214
of gavage in malnutrition, 137
in persistent vomiting, 135
of hematemesis from blood in
breast milk, 183
of hemophilia, 450
of history of marasmus, 152
of hyperpyrexia from ulcerative
stomatitis, 221
of hysteria in the third generation,
360
of ileocohtis, 200
of inactive type of intestinal infec-
tion, 198
of incubation period of pertussis,
322
of intestinal obstruction due to
Meckel's diverticulum, 210
of intubation, 313
of intussusception, 212
Cases, illustrative, of malignant endo-
carditis, 293
of masturbation, 435
of mildness of pertussis, 323
of milk-giving in typhoid, 458
of mucous colitis, 206
phenomena of intestinal indiges-
tion, 162
of myocarditis, 295
of nervous causes of vomiting, 176
of night-terrors from overeating,
365
of oil treatment for constipation,
175
of otitis media, 419
of overfeeding in nurslings, 69
of persistent glycosuria, 349
of post-diphtheritic paralysis, 380
of primary tuberculous pleurisy
with effusion, 280
of quarantine, 301
of rectal feeding, 141
of recurrent bronchitis, 465
without asthma, 261
of retropharyngeal abscess, 243,
244
of rheumatism in acute endocardi-
tis, 292
in asthma, 264
of rickets, wet-nursing, 442
of round-worm infection, 215
of septic infection of the navel, 50
of severe intestinal infection, 198
of tardy malnutrition, 159
of thyroid extract in cretinism,
446'
of traumatic laryngitis from the
inhalation of carbolic acid, 253
of ulceration of the stomach, 184
of unexplained temperature, 480
of use of antitoxin before diagno-
sis, 303 _
in intubation cases, 305
of lavage in vomiting, 182
Castor oil, 197
administration of, 503
in bronchitis, 260
in constipation, 174
in convulsions, 364
in icterus neonatorum, 50
in ileocohtis, 201,206
in influenza, 452
in intestinal indigestion, 161
infection, 197
in laryngitis, 248
in round-worms, 214, 215
in summer complaint, 189
in tape-worm, 216
in tetany, 366
in urticaria, 408
in worms, 214-216
initial dose in acute gastro-intes-
tinal infection, 192
INDEX
569
Catarrh, nasal, due to adenoids, 232
to hay-fever, 232
to liyi)ertn)phied turbinates, 232
to Klcbs-Lofller bacillus, 232
to malnutrition, 232
treatment of, 233
Catarrhal pneumonia. See Pneumo-
nia, broncho-.
Catheterization of larynx in asphyxia
of the newly born, 49
of urethra in retention of urine, 337
Catheters, soft-rubber, as stomach-
tubes, 136
CauHflower, when allowed, 131
Cauterization of hypertrophied tonsils,
239
of nasal septum in nasal hemorrhage,
234
Cavities in first teeth, 35
Cephalhematoma, 50
suppuration in, 50
treatment of, 50
Cereal gruels, 119
beginning feeding of, 120
in acute illness, 120, 133
intestinal infection, 197
in condensed milk feeding, 114
in cow's milk, idiosyncrasies, 110
in difficult cases, 109
in feeding dispensary patients, 93
in milk adaptation, 97
not good for an exclusive diet, 120
percentages of, 124
to replace milk, 120
variety in kind of value, 192
Cereals, high proteid, 145
in nephritis, 344
ready to serve, 145
when allowed, 128
with butter and sugar, 1 74
Cerebellar ataxia, hereditary, 527
Cerebral palsy associated with idiocy,
385
varieties of, prenatal, birth, post-
natal, 383
Cereo for dextrinizing cereal gruels,
124
in typhoid fever, 457
Cerium oxalate in gastric indigestion,
178
Certified milk, 188
requirements of the New York
Covmty Medical Society Milk
Commission for the production
of, 104
Cervical adenitis due to adenoids, 424
to decayed teeth, 424
to large tonsils, 424
in typhoid fever, 457
caries, tubercular, 245
Chair suitable for children, 510
Changes in temperature, sudden, dan-
gerous in nephritis, 500
Chapin dipper, 84, 171
Cheese cloth for diapers in typhoid
fever, 457
Cherries, when allowed, 131
Chicken broth, formula f(jr jircparing,
123
Chicken-pox, 332. See also Varicella.
Child nagging, 58
Chill in onset of pneumonia, lobar,
272
in pyelitis, 352
Chilling skin a cause of suppression of
urine, 337
Chloral hydrate, 185
in convulsions 364
in laryngismus, 252
in meningitis, 375
in tetanus neonatorum, 54
in uremic convulsions, 346
Chlorate of potash, effect on kidneys,.
223
in stomatitis, 222
in tonsillitis, 239
Chlorid of iron, administration, 504
Chloroform as an anesthetic in children,
495
as a counterirritant, 493
contraindications for, 495
danger-signals in use of, 495
in asthma of older children, 265
in convulsions, 364
sudden death from, 449
Chlorosis, 438
country Hving in, 440
treatment of, 440
Cholelithiasis causing jaundice, 437
Cholera infantum, 191
Chorea, 367-370
anti-rheumatic diet in, 368
arsenic in, 369
aspirin in, 369
associated with cardiac disease, 296
bicarbonate in, 368
candy in, 368
Fowler's solution in, 369
intermittent medication in 369
meat eating in, 368
play in, 368
rest treatment in, 367
rheumatism in, 367, 368
salicylates in, 368
school in, 368
sugar in, 368
Choreiform movements due to intes-
tinal toxemia, 162
Chrysarobin in ringworm of the scalp,.
414
Circumcision, 354
after balanitis, 354
death of a bleeder after, 451
for masturbation, 434
for paraphimosis, 354
for phimosis, 353
570
Circumcision for the relief of painful
micturition, 336
Citrate of iron. See Iron.
of magnesia. See Magnesia.
of potash. See Potassium.
Clean milk, cost of producing, 103
Cleft-palate, 398
feeding in, 399
operation for, 398
Climate, change of, to cure grippe, 454
in asthma, 263, 500
in bronchiectasis, 287
in care of delicate children, 143
in cure of poor appetite, 126
in intestinal diseases, 186, 203
in nephritis, 349
in pulmonary diseases, 501
in tuberculosis, 285, 501
therapeutic value of, 500
Clitoris, adhesions of, a cause of incon-
tinence of urine, 338
of masturbation, 434
deterrent to growth, 143
Clothing, 509
average weight of, 32
for dehcate children, 147
for summer months, 487
for use in gymnastic therapeutics,
506
in anemia, 439
in bronchopneumonia, 267
in lobar pneumonia, 274
too heavy in sickness, 19
Coal-tar products in typhoid fever, 459
Coast towns in summer, 500
Cocain anesthesia for thoracotomy, 282
in earache, 418
in fissure of anus, 214
in pertussis, 325
Cocoa in malted milk, 172
Coddled egg in ileocolitis, 205
Codein in asthma, 265
in cough of measles, 222
of pleurisy, 279
in diphtheritic paralysis, 380
in endocarditis, 291
in meningitis, 375
in multiple neuritis, 382
in pericarditis, 371
in pertussis, 327
Cod-liver oil, 371
in bronchiectasis, 285
in cardiac disease, 298
in condensed milk feeding, 164
in constipation, 170
in marasmus, 156
in milk idiosyncrasy, 110
in neuritis, 382
in neurotic children, 363
in nurslings, 168
in persistent adenitis, 425
in tubercular adenitis, 430
in vulvovaginitis, 357
Coffee after sixth year, 132
in typhoid, 457
insufflations of, in pertussis, 324
Coit, H. L., organizer of the first milk
commission, 103
Cold air, contraindicated in asthma,
265
baths, uses of, 499
coil, use of, 499
compress in catarrhal croup, 249
in tonsillitis, 239
use of, 499
cream inunction in measles, 331
douche in neurotic children, 362
uses of, 500
dry air in summer, 500
feet and colic, 165
foods, better retained than hot, 178
in delicate children, 147
pack, 481
in bronchopneumonia, 270, 271
in diphtheria, 310
in endocarditis, malignant, 293
in erysipelas, 463
in fever, 476
in gastro-intestinal infection of the
choleraic type, 191
in influenza, 452
in lobar pneumonia, 275
sponging in fever, 480
in grippe, 452
in hot weather, 481
in pneumonia 271
in typhoid fever, 456, 460
uses of, 499
therapeutic uses of, 499
water enema after colon flushing,
198
Cold, chronic, due to adenoids, 427
in head, 228, 229
Colic causing hernia, 395
due to decomposition, 165
to defective bowel action, 165
to milk proteid, 165
to mother's constipation, 165
to round-worms, 214
to too much fat, 89
to too much proteid, 89
to too strong food 89
in bottle-fed, 165
in breast-fed, 165
in difficult feeding cases, 108
nervous causes of, 165
stupes in, 494
treatment of, 253
Coliopyelitis, 352
Colitis, as cause of fecal incontinence,
218
chronic, years to get results in, 18
Collecting urine, device for, 336
Colon bacillus in cystitis, 351
in urine of pyelitis, 352
flushing, 496
INDEX
57]
Colon flushing, apparatus for, 208
in cyclic .vomiting, 472
in gastro-inlestinal infection, 191,
192, 193
in ileocolitis, 205, 207
in intestinal infection, 198
in mucous colitis, 206
in nephritis, 345
in persistent vomiting cases, 178
in pneumonia, lobar, 278
in suppression of urine, 337
indications for, 208
irrigation in acute intestinal infec-
tion, 199
in fever, 208
medication in laryngismus stridu-
lus, 253
Colostrum, 72
Coma, gavage of peptonized milk in,
115
Comfort baths for hot weather, 30
Condensed milk after diarrhea, 196
analysis of, 114
as cause of malnutrition, 151
of rickets, 442
as sick food, 114
for summer, 155
for travehng, 116
in convalescence of ileocolitis, 204
in difficult feeding cases, 108
in out-patient work, 93
in premature infants, 47
Conduct of life in valvular disease of
the heart, 296, 299
Congenital defects causing intestinal
obstruction, 209
heart disease, 299
pyloric stenosis, 185
Congestion, internal, 494
counterirritation for, 494
Constipation after diarrhea, 197
after ileocolitis, 204
cascara in, 168
due to fissure of the rectum, 170
to inflammation of anus, 213
to sterihzing milk, 1 1 1
to too high fat, 171
to too low fat, 67
gymnastic exercises for, 539
in bottle-fed, 169
in chronic ileocolitis, 205
in difficult feeding cases, 109
in mucous colitis, 206
in nursing mothers, 65
a cause of colic in child, 165
of constipation in child, 167
treatment of, for eczema in child,
401
in nurshngs, 167
in older children, 170
in peritonitis, 469
not an index of intestinal toxemia,
162
Constipation, treatment of, 166-168
Contagious diseases, care to be exer-
cised in attending, 300
Continence of urine, when established,
336
Convulsions, infantile, a cause of cere-
l)ral hemorrhage, 364
of epilepsv, 364
chloral in, 364
chloroform inhalations in, 364
diet after, 364
due to atelectasis, 5 1
to enlarged thymus, 365
to gastro-intestinal irritation,
363
to phimosis, 363
to rachitis, 363
to worms, 214
from birth trauma, 363
in acute nephritis, 347
in dentition, 36
in pertussis, 323
in onset of acute intestinal infec-
tion, 199
of lobar pneumonia, 272
management of, 364
uremic, 347
Cooling of milk, 106
Cooperation of mother in treatment
of the children, 19
Cord, 26. See Umbilical cord.
stump, cauterization of, in tetanus
neonatorum, 54
Corn starch, when allowed, 130
Cornmeal gruel in the diet of the nurs-
ing mother, 70
Corrosive drugs as source of gastritis,
177
Coryza, recurrent, 233
associated witli cardiac disease,
296
Cough in laryngitis, 246
chronic, due to adenoids, 426
paroxysmal, but not pertussis, 323
pharyngeal, 236
Counterirritants for relief of conges-
tion, 493
Counterirritation in acute gastric indi-
gestion, 178
in bronchitis, 259
in bronchopneumonia, 268
in lobar pneumonia, 275
in pleurisy, 279
Country living in chlorosis, 447
Cow's milk. See Milk, coiv's.
Cracked wheat, when allowed, 130
Cream, age of, for infant feeding, 83
Alderney, 107
centrifugal, 107
digestibility of gravity and centrif-
ugal, 108
gravity, 107
Jersey, 107
572
Cream in constipation before nursing,
168
mixtures, 155
Crede's ointment in cervical adenitis of
scarlet fever, 319, 424
Creolin baths in pemphigus, 409
Creosote, administration of, 504
in chronic bronchitis, 261
in pertussis, 325
in steam inhalations, 258
Cretinism, 385, 445
Crisis in lobar pneumonia, 273
Croup, catarrhal. See Laryngitis, acute
catarrhal.
diphtheritic. See Diphtheria, laryn-
geal.
in bronchitis, 258
kettle, 248
spasmodic, 246
Crying, habitual, due to discomfort, 27
necessary at birth, 51
use of, 26
varieties of, 27
Curds in stools, due to too high proteid,
68
of breast-fed, 68
Custard, frozen, in illness, 134
when allowed, 130
Cyanosis due to atelectasis, 51
CycHc vomiting, diet in, 472
drugs in, 473
due partly to rheumatic taint, 472
Cystitis, 351
as cause of incontinence of urine, 338
rare, in boys, 351
Dactylitis, syphiHtic, 470
tuberculous, 470
Danger-signals in ether, gas, and chlo-
roform, 495
Dark room in measles, 330
Day terrors, 1 62
Deaf children, often regarded as stupid,
422
Deafness, acquired, 422
due rarely to mumps, 422
to adenoids, 422
to enlarged tonsils, 422
to eustachian disease, 422
to middle ear disease, 422
following scarlet fever, 320
temporary, in diphtheria, grippe,
tonsillitis, and the exanthemata,
422
transitory, in pertussis, 323
Death from acute gastro-intestinal
infection, 191
atelectasis in the newly born, 58
from persistent hematemesis from
ulcer of the stomach, 185
Death-rate due to measles, 330
to pertussis, 321
Decubitus, sites of, 413
Delicate child, care of, 143-150
definition of, 142
examination of, 143
parents beget delicate children, 143
Delphinium, 414
Delusions, optical, in intestinal toxe-
mia, 163
Deming milk modifier, 90, 91
Denhard gag, 137, 428
Dentition as cause of convulsions, 36
of digestive disturbances, 36
diet during, 36
disturbances of, 36
feeding during, 36
in respiratory diseases, 36
in skin diseases, 36
in well children, 36
late, 36
multiple, 36
Depressed nipples, 79
Dermatitis gangrenosa a sequel of
chicken-pox, 333
Detail in the treatment of children, 17
Development at the Babies' Hospital
Dispensary, 56
percentage of normal development
in the New York Polyclinic Out-
patient Department, 56
Dew method of artificial respiration,
48
Dextrinized barley-water, formula for
making, 124
gruels after diarrhea, 196
after ileocoUtis, 204, 205
Diabetes insipidus, 350
melUtus, 350
diet in, 351
drugs in, 351
fatality in, 351
loss of weight in, 351
thirst in, 351
urine in, 351
Diacetic acid, absence of, in glycosuria,
350
Diachylon plaster in the treatment of
decubitus, 413
Diaper washer, 20
Diapers, 20
care of, 20
protector for, 20
Diarrhea, a conservative process, 193
due to too high fat, 67, 166
in typhoid fever, 459
initial treatment of, in breast-fed,
161
onset of, 160
stopping milk in, 161
Diarrheal diseases, etiologic factors in,
187
Diet after adenoid operation, 429
after the sixth year, 132
antidiabetic, 351
INDEX
573
Diet, antirheumatic, in chorea, 368 I
during dentition, 36
illness, 133
second year, 56
often too low in proteid, 128
high proteid, in delicate children,
144
in adenitis, tubercular, 430
in anemia, 439
in bronchitis, 258
recurrent, 262
in bronchopneumonia, 267
in cardiac disease, 297
in constipation, 171
in convulsions, 364
in diabetes, 351
in diphtheria, 309
in endocarditis, acute, 291
in epilepsy, 372
in erythema nodosum, 409
in incontinence of feces, 219
in influenza, 452
in intestinal indigestion, 163
in jaundice, obstructive, 437
in laryngismus stridulus, 253
in lobar pneumonia, 275
in measles, 331
in mucous coUtis, 207
in nephritis, 348
in night-terrors, 365
in rheumatism, 464, 466
in rickets, 443
in scarlatina, 315
in tardy malnutrition, 159
in tuberculosis, pulmonary, 285
non-constipating, after second year,
172
for five to ten years, 173
schedule, for feeding, after the first
year, 129-132
Dietetic errors, a predisposing cause to
rheumatism and endocarditis, 464
Diificult feeding cases, due to cow's
milk intolerance, 108
Digestion of starch, 120, 121
disorders of, due to dentition, 36
Digestive power, best in morning, 159
Digitalin in acute intestinal infection,
199
Digitalis, abuse of, 299
administration, 504
as a heart stimulant for young chil-
dren, 277
in bronchopneumonia, 270
in cardiac disease, 296, 298
in diphtheritic paralysis, 381
in ileocoHtis, 202
in myocarditis, 293
in nephritis, 343
in scarlet fever, 318
use may be attended with harm, 19
Dilatation of stomach, 1 83
causing vomiting, 175
Dilatation of stomach jn chronic gas-
tritis, 179
in marasmus, 154
Diluted food in bronchitis, 258
in bronchopneumonia, 267
in illness, 133
in scarlet fever, 315
in tonsilhtis, 238
Dilution of drugs, 504
Dining alone, 132
Diphtheria, antitoxin rash in, 307
a cause of acute endocarditis, 307
and myocarditis, 293
cause of, 302
cervical adenitis in, 302
cool pack in, 302
effect of antitoxin on membrane in,
304
on temperature in, 304
foul breath in, 302
gargle in, 309
gavage in, 302
general treatment in, 309
inhalations in, 309
Klebs-Loffler bacillus in, 302
laryngeal, 304
antitoxin dosage in, 304
intubation in, 312-314
onset of, 304
late giving of antitoxin in, 306
leukocytes in, 307
location of membrane in, 302
nasal, 230
rectal feeding in, 300
sponge bath in, 300
spray in, 309
strophanthus, in, 300
strychnin in, 309
throat irrigation in, 245, 309
transmission by kissing, 28
vaporization in, 309
versus streptococcus throat, 304
Diphtheritic paralysis, percentage of
occurrence of, 379
peptonized milk by gavage in, 115
Diplegia, 384
Directions for the care of the child,
41
Disinfection of the excreta in typhoid
fever, 457
Disorders of speech due to intestinal
toxemia, 162
Dispensary patients, feeding of, 91
written instructions for the feed-
ing of, 189
Diuretics in nephritis, 346
Double mirror for gymnastic exercises,
506
room for sickness, 454
Douche bag for ear irrigation, 421
cold, 29
Dover's powder, 332
in bronchitis, 219
574
Dover's powder in cough of broncho-
pneumonia, 270
in diarrhea, 194
in fever, 477
in ileocohtis, 201
in laryngitis, 249
in rhinitis, 231
in typhoid fever, 459
with bismuth in fecal incontinence,
219
Drafts, 57
Drainage of summer home, 492
Drinking water in measles, 331
with meals, 184
Drop method for ether anesthesia, 495
Drugs and drug dosage, 545-561
nauseating and unpalatable, 502
those which may harm, 19
use of, in cardiac disease, 296
in endocarditis, 291
in gastro-intestinal indigestion,
178
in meningitis, 375
promiscuous use of, by family, 501
Dry supper in treatment of inconti-
nence of urine, 340
Duodenitis causing obstructive jaun-
dice, 437
Duration of tub-baths, 29
Dust, importance of, in measles-pneu-
monia, 330
Dusting-powder, 26
in furunculosis, 412
in gonorrheal vaginitis, 358
in granuloma, 53
in intertrigo, 404
in prickly heat, 417
in vulvovaginitis, 357
Dysarthria due to intestinal toxemia,
'163
Dysphagia in retropharvngeal abscess,
242
in tonsilhtis, 238
Ear, examination, 420
pulhng, 432
syringes, 421
Earache, camphor water in, 418
measures to relieve, 418
Eating, bad, 57
between meals, causing loss of appe-
tite, 126
utensils, care of, in the sick-room,
301
Eczema about a suppurating navel,
26
as cause of malnutrition, 401
associated with acid urine, 401
with high fat, 402
sugar, 402
with recurrent bronchitis, 401
due to faulty metabolism, 401
Eczema due to maternal nursing, 401
to salivation, 220
to soaps, 403
to woolens, 403
fresh cow's milk in, 402
intertrigo, 403
neurotic, 404
of older children, 404
seborrheic, 406
treatment of, external, 402, 403
washing face in, 403
Edema of larynx, intubation in, 310
Education of mother about feeding,
189
Eggs, excluded in the diet of neph-
ritics, 348
in delicate children, 145
soft-boiled, when allowed, 130
Egg-water, formula for making, 123
Electricity in Erb's paralysis, 386
in facial paralysis, 383
in multiple neuritis, 382
in poliomyelitis, 379
Electrotherm in premature infants,
45, 46
uses of, 499
Elixir simplex as a vehicle, 504
Emphysema due to asthma, 264
Empty stomach, giving drugs on, 504
Empyema, development of, 281
double, 284
encysted, a cause of obscure eleva-
tion of temperature, 479
exploration of chest in, 281
insufficient drainage in, 282
irrigation of the cavity, 383
mistaken for tuberculosis, 280
for typhoid, 281
for unresolved pneumonia, 28 1
necessitatis, 284
pocketing of pus in, 283
removal of tube after thoracotomy
for, 283
resection of a rib for, 281
thoracotomy for, 281
Endermic feeding, 138
Endocarditis a part of rheumatism,
463
diet in, 291
heart action in, 292
ice cap for, 291
in diphtheria, 290
in influenza, 290, 453
in rhevmiatism, 290
in scarlet fever, 290
malignant, with diphtheria, 293
witli scarlet fever, 293
with tonsillitis, 293
rheumatic, recurrence, 296
salicylates for, 292
septic, 293
Enema after ileocohtis, 204
in cohc, 165
INDEX
575
Enema in constipation, 170, 166
ot nursing mothers, 66
in convulsions, 364
in ileocolitis, 205
in pneumonia, lobar, 274
in typhoid fever, 458
initial treatment of all cases of
vomiting, 177
nutrient, 141
soapsuds, 166, 376
standing order for, 166
Energy expended by a child, 28
Enterocolitis a cause of peritonitis,
469
alcohol in, 498
Enuresis, 338. See also Incontinence
of urine.
Environment, 431
a factor in artificial feeding, 80
in growth of child, 55
in intestinal diseases, 186
in marasmus, 153
unfavorable, 186
Epilepsy a contraindication to mater-
nal nursing, 71
bowel function in, 372
bromids in, 372
diet in, 372
due to infantile convulsions, 364
fatigue in, 372
institutions for, 371
intestinal toxemia in, 372
irritative lesions in, 372
management of, 371, 372
Epiphyses, enlarged, 441
separation of, in scurvy, 445
Epispadias, 353
Epistaxis, 234. See also Nasal hemor-
rhage.
Epitrochlear glands, enlarged, in syph-
ilis, 390
Epsom salts in enema, 198
Erb's paralysis, 386
Ergot in pemphigus, 378
in purpura, 450
Ermold, George, lamp for calomel
fumigations, 250
Errors in feeding, 127
Erysipelas, 461-463
applications for, 462
drugs for, 462
feeding in, 462
following vaccination, 485
varicella, 333
hygiene in, 462
in the newly born, 49
mortality of, 461
scarifications for, 461
Erythema multiforme, 410
nodosum, 409
diet in, 409
duration of, 409
in peliosis rheumatica, 468
Erythema nodosum, lead and opium
f(jr, 409
potassium iodid for, 409
rheumatic nature of, 409
Ether, anesthesia by preference, in
adenoids, 428
contraindications for, 495
danger signs of, 405
in cliildren, 494
Ethyl clilorid, 405
Eustachian tube, catarrh of, as cause
(jf persistent deafness, 422
due to adenoids, 239
to tonsils, 239
infected by nasal syringing, 231
Evaporated cream, 114
Every-day care of feeding, 56
Ewing, James, quoted, 307
Examination, Ijefore gymnastic thera-
peutics, 305
monthly, 32
of delicate child, 143
of ear drum, 418
of patient, first, 39
of throat, 239
Exercise as cause of elevation of tem-
perature in nervous children,
477
baskets, 25
conditions under which to be taken,
505
effect on the milk of nursing mother,
69
for correcting postures, 5 1 2
for delicate child, 149
for nursing mother, 66
in cardiac disease, 297
in cure of obesity, 438
in nephritis, 349
pen,
26, 37, 148, 229
Expectorant treatment in catarrhal
croup, 248
Expectorants in bronchopneumonia,
269, 270
Exploration of chest, 281
Expression of milk during suspended
nursing, 161
External auditory meatus in mas-
toiditis, 423
Extractum ferri pomatum, 440. See
also Iron.
Extravasation of blood in pertussis,.
324
Exudate, pleural, 278
Eyes, care of, in measles, 331
Eyestrain, headache often the only
sign of, 359
Face mask in eczema, 403
Facial paralysis due to otitis, 382, 383
Farina gruel as a cereal, when allowed,
730
576
INDEX
Parina gruel when allowed, 129
Fat an essential ingredient of food,
59
as cause of malnutrition, 157
badly borne in ileocolitis, 205
diarrhea due to, 95
excess of, in food, signs of, 95
function of, 60
high, occasional cause of constipa-
tion, 169
in proprietary foods, 117
indigestion, 95
a factor in the constipation of
bottle-fed babies, 169
signs of, 95
inunctions, 138
limit of, for older children, 171
low, an occasional cause of consti-
pation, 167
where found, 60
Fatigue a cause of fever, 478
of headache, 359
in chorea, 367
in epilepsy, 372
Faucitis, 235
treatment of, 236
Fecal impaction causing intestinal
obstruction, 210
masses a cause of fissure, 213
Feces, incontinence of, 218
starch converting enzyme in, 121
Feeding after diarrhea, 194
first year, 128-132
ileocolitis, 23
vomiting, 193
artificial, 80-98
defective, a cause of tardy malnu-
trition, 159
forced, in tuberculosis of children,
285, 471
frequency of, in chronic ileocohtis,
205
in acute gastro-indigestion, 178
in delicate children, 144, 145
in erysipelas, 462
in gastritis, chronic, 179
in illness, art of, 134
in malnutrition of infants, 157
in marasmus, !54, 155
in premature infants, 47
in sepsis, 49
in sprue, 224
in stomatitis, 222
in tonsillitis, 238
in typhoid fever, 457, 458
methods, faulty, a cause of diarrheal
diseases, 187
instructions in, for poor, 189
of fuU milk, 92
substitute, Chapin dipper for, 85
condensed milk and, 92
diluting milk in, 82
for dispensary patients, 91
Feeding, substitute, full milk, 92
home modification in, 93
intervals in colicky babies, 165
laboratory feeding, 89
milk adaptation in, 94-98
modifying milk, 81
number of feedings, 85-88
whey and cream mixtures in, 86
through skin, 138
too frequent, a cause of loss of appe-
tite, 125
Fetor of breath in noma, 224
Fever in acute illnesses, 475
in chronic discharging ear case, a
sign of mastoiditis, 423
in otitis, 419
persistent, due to intestinal toxemia,
162
Finger sucking, 432
Fireplace as ventilator, 43
Fish, when allowed, 131
Fissures at angle of mouth, 226
of anus, 213
of lips, 226
of rectum a cause of constipation,
170
Flat chest, causes of, 511
exercises for, 516-518
rare in infants, 511
Flat-foot, examination for, 543
exercises for, 544
massage for, 544
shoes for, 545
Floor, playing on, 147
sitting on, a cause of colds, 228
Florida for nephritis cases, 500
Fluid in the chest, 279
Food, adaptation of, 60
assimilation, key to infant feeding,
56, 60
decomposed, a cause of gastric indi-
gestion, 177
for premature babies, 47
forcing, 128
fried, 132
infected, a cause of summer diarrhea,
186
properties and ingredients, 59
proprietary, a cause of rickets, 442
containing alcohol, 363
quantity of, at a feeding, 127
temperature of, in stomatitis, 221
too concentrated, a cause of consti-
pation, 171
too strong, signs of, 88, 94
too weak, signs of, 88, 94
unsuitable, a cause of acute gastric
indigestion, 177
utensils, care of, in congenital syphi-
lis, 389
in quarantine, 301
Forceps, laryngeal, 254
Foreign bodies in larynx, removal of, 254
577
Foreign bodies in nose a cause of nasal
catarrh, 232
Foreskin, incision of, in paraphimosis,
354. See also Circumcision.
Formalin in sprue, 224
Formulce for condensed milk mixtures,
93
for feeding dispensary patients, 92,
93
well babies, cream and milk mix-
tures, 84, 85
for making barley jelly, 123
barley-water, 123, 124
beef-broth, beef-juice, chicken-
broth, 123
dextrinized barley-water, 124
egg albumin water, 123
imperial granum water, 124
junket, 125
mutton broth, 123
oatmeal water, 124
wheat jelly, 123
whey, 124
for top-milk mixtures, 87
for whole milk mixtures, 92
Foul breath in diphtheria, 302
in noma, 224
in ulcerative stomatitis, 221
Fowler's solution in chorea, 369
susceptibility to, 370
Freeman's pasteurizer, 1 1 1
Fresh air, difficult to secure, 57
for nursing mother, 66
in anemia, 439
in bronchitis, 258
in bronchopneumonia, 267
in delicate children, 146
in erysipelas, 462
in growth of child, 57
in lobar pneumonia, 274
in marasmus, 153
in pertussis, 328
in premature infants, 45
in tuberculosis, 286
cow's milk in eczema, 402
in scurvy, 445
Friedreich's ataxia, exercises for, 527
Fright causing vomiting, 176
Fruit during lactation, 65
when allowed in diet, 130, 131
Fumigation after grippe, 454
Furnishings of sick-room, 43
Furniture for children, 510
Furunculosis, 411
after varicella, 333
treatment of, 411, 412
Gain in weight, amount of, in success-
ful maternal nursing, 67
normal, under one year, 144
Galvanocautery in cure of hyper-
trophy of tonsils, 240
37
Gargles in diphtheria, 309
Garhc, infusion of, in thread-worms,
215
Gas-ether anesthesia, 495
Gastritis, acute, beginning grippe, 453
causes of, 176
treatment of, 177
chronic, 179
barley-water in, 1 79
cause of, 179
following acute, 178
treatment of, 179
Gastro-enteritis as cause of suppres-
sion, 337
cereals to replace milk in, 120
complicating erysipelas, 462
pertussis, 323
onset of, 191
symptoms of, 191
termination of, 193
treatment of, 191
Gastro-enterostomy in congenital py-
loric stenosis, 86
Gastro-intestinal intoxication, 191
irritation as cause of convulsions, 363
Gavage, 134-136
amount of, 137
frequency of, 137
in cleft-palate, 399
in diphtheria, 310
in hare-lip, 398
in lobar pneumonia, 277
in marasmus, 152, 153
in meningitis, 375
in persistent vomiting, 1 78
in post-diphtheritic paralysis, 380,
381
in sepsis, 49
in tetanus neonatorum, 54
Genitals, female, 357
uncleanUness of, in difficult uri-
nation, 336
male, 352
Geographical tongue, 227
Giant hives, 387
Gin in colic, 166
Ginger-ale, 134
Gingivitis in typhoid fever, 457
Girls, hysteria in, 360
masturbation in, 433
Glands of neck in diphtheria, 302
in tonsillitis 237
retropharyngeal, suppuration of, 242.
See also Adenitis, cervical.
Glandular fever, 47 1
Glass-tube for taking iron, 504
Glasses for relief of headache, 359
Glauber's salt in gastro-intestmal m-
fection, 192
Glycerin suppository, 166
adjuvant in oil treatment of con-
stipation, 174
Glycosuria, diabetic, 350
578
INDEX
Glycosuria, dietetic, 349
temporary, 349
Gonorrhea in female, 357
bacteriologic examination before
discharge of case of vaginitis, 358
method of infection of, 357
treatment of, 358
in male, 355
in nursery maids, 23
Good food, most important factor in
nutrition, 55, 56
Goose oil rub, 139, 146, 158
in tetany, 367
in tuberculosis, 287, 371
Granuloma, 26, 53
Granum-water, 179
after gastro-intestinal infection, 192
formula for, 124
Green vegetables in diet of child, 145
in rheumatism, 464
Grindelia robasta in ivy-poisoning, 411
Grippe, 452. See also Influenza.
Ground-floor, child to sleep above,
492
Growing pains a part of rheumatism,
463
Growth of child as regards his future,
55
Gruels. See Cereal gruels.
Gums, bleeding, in ulcerative stomati-
tis, 453
Gymnastic therapeutics, 505-544
adaptation to practical ends in,
507
anterior poUomyelitis treated by,
541
breathing in, 513
congenital ataxias treated by, 526
constipation treated by, 539
duration and frequency of treat-
ments in, 501-506
exercises for correcting bad pos-
tures, 512
flat chest, exercises for, 516-518
for Friedreich's ataxia, 527
for hereditary cerebellar ataxia,
527
flat-foot treated by, 543
general considerations in, 509
kyphosis treated by, 518, 519
period of treatment in, 507
posture and breathing in, 506
scoliosis treated by, 521
Gyrospasm, 365
in idiots, 366
H.\BiT cough, 255
spasm, 370
diet in, 371
drugs in, 371
related to chorea, 371
to rheumatism, 371
Habits of bowel evacuation, 166
of ear pulling, 432
of masturbation, 432
of self -entertainment, 432
of sleep, 432
of thumb-sucking, 432
to be discouraged, 432
to be encouraged, 432
Hands, care of, after diapering, 20
Hare-lip, 398
feeding in, 398
operation for, 398
Hay-fever, a cause of nasal catarrh,
232, 263
Head covering a cause of colds, 228
nodding, 365
position of, in retropharyngeal ab-
scess, 242
rest for preventing decubitus, 413
Headache a possible sign of meningitis,
359
due to eye-strain, 359
to intestinal indigestion, 359
to nitroglycerin, 277
habitual, an evidence of intestinal
toxemia, 162
in malaria, 359
in nephritis, 359
in onset of acute infections, 359
in pneumonia, 359
in scarlet fever, 359
Hearing, acuteness, in early months, 422
age established, 422
Heart, action of, in acute endocarditis,
292
in myocarditis, 294
in post-diphtheritic paralysis, 380
disease, congenital, 299
length of life in, 299
manner of death in, 299
treatment of, 299
valvular, 296-299
associated with chorea, 296
with recurrent bronchitis, 296
with tonsillitis, 296
conduct of life in, 296, 297
diet in, 296
digitahs, 298
exercise in, 296
origin of, in rheumatism, 296
prognosis in, 297
sugar eating in, 296
treatment of, 296-299
failure in diphtheria, 306
rest, 293, 295, 298
stimulants, 299
abuse of, 299
in pneumonia, 270, 276
indications for, 299
Heat, dry, in nephritis, 346
in pain of neuritis, 382
therapeutic applications of, 498,
499
579
Height, significance of, 34
table of, 34
Hematemesis due to Henoch's purpura,
183
to swallowing blood, 183
to ulcers, 183, 184
in cyclic vomiting, 472
of newly born, 183
persistent, an evidence of ulcer of
stomach, 185
treatment of, 185
Hematoma of sternomastoid, 398
Hemiplegia, 384
Hemophilia, 450
hereditary transmission in, 431
in hemorrhagic diseases of the newly
born, 54
treatment of, 450
Hemorrhage, cerebral, due to convul-
sions, 364
from stomach, 183. See also Hema-
temesis.
meningeal, causing cerebral palsy, 383
Hemorrhagic diseases in the newly
born, 53
treatment of, 54
Hemorrhoids rare in children, 218
Hereditary cerebellar ataxia, 527
Heredity and environment, 431
as factor in posture, 511
in growth of a child, 55
in hemophilia, 450
in hysteria, 360
Hernia, inguinal, 395
causes, 395
occurrence, 395
operation for, 395
trusses for, 395
strangulated, causing intestinal ob-
struction, 210
umbilical, 396
treatment of, 396
ventral, 397
treatment of, 397
Herniotomy, 395
Hiccough due to distention of stom-
ach, 387
High fat after diarrhea, 195
mixtures in constipation, 171
proteid diet for child in school, 57
in malnutrition, 158
Hirt, quoted, 368
History, family, importance of, 39
taking, 39
Hives, 407. See also Urticaria.
Hoarseness in congenital syphilis, 390 I
Holt's croup-kettle, 248
milk-set, 76
Hominy, when allowed, 130
Honey and borax for sprue, 224
Hot air, use of, 499
and cold baths in asphyxia of newly
bom, 48
Hot batli for acute gastro-intestinal in-
fection. 191
in nej^hritis, 346
in tetany, 336
to bring out measles-rash, 331
uses of, 498, 499
fomentations in mumps, 334
irrigation of throat, 241
use of, 498, 499
packs in nephritis, 346
uses of, 498, 499
poultices, use of, 498, 499
stupes in colic, 165
in ileocolitis, 202
in retention, 337
use of, 498, 499
Hot-water bag in acute gastro-intestinal
infection, 191
in earache, 418
use of, 498, 499
Hot-water douche in earache, 418
Human milk, percentage composi-
tion of, 67. See also Milk, human.
Hutchinson's teeth, 391
Hydrocele, 356
Hydrocephalus, chronic internal, 377
Hydrochloric acid, 126, 184, 437, 458
Hydrogen peroxid, 218, 222, 233, 354
Hydronephrosis as cause of intestinal
obstruction, 210
Hydrotherapy in typhoid fever, 460
Hyperpyrexia in ulcerative stomatitis,
221
Hypnotics, duration of administra-
tion, to children, 382
Hypodermic feeding, 138
stimulation, 277
Hypophosphites, syrup of, 164, 288, 430
Hypospadias, 353
Hysteria, attacks of, 362
environment in, 360
heredity in, 360
treatment of, 361
Ice-bag in adenitis, 424
in appendicitis, 211
in convulsions, 364
in endocarditis, 291
in glandular fever, 471
in headaches due to fever, 359
in mastitis, 79, 52
in nasal hemorrhage, 234
in pericarditis, 290
in poliomyehtis, 378
in quinsy, 241
in typhoid fever, 461
uses of, 499
Ice-cream in illness, 134
when first allowed, 131
Ice-stations, municipal, 188
Ichthyol in albolene for chronic rhini-
tis. 233
58o
INDEX
Ichthyol in olive-oil as an inunction for
chicken-pox, 333
ointment in adenitis, 333, 424
in contagious impetigo, 408
in eczema, 403
in erysipelas, 49, 462
in fissure of anus, 214
of lips, 226
of mouth, 226
in furunculosis, 411
in German measles, 333
in hemorrhoids, 218
in inflammation of anus, 213
in mastitis of newly born, 52
in ulcers of nasal septum, 234
Icterus, 437
neonatorum, 50
Idiocy, 384
after convulsions, 363
with gyrospasm, 366
Ignorance an important factor in poor
feeding, 57
Ileocolitis, acute, bacteriology of, 200
blood in stools of, 200
colon flushing in, 202
constipation after, 204
diet in, 200
drugs in, 201
duration of, 200
during convalescence, 203
feeding during attack, 200
following acute gastro-intestinal
infection, 193. 200
pathologic findings in, 199
prostration in, 200
starch injections in, 203
stools in, 200
temperature in, 200
tenesmus in, 200
treatment of, 201-204
chronic, 204
causing malnutrition, 204
following acute, 204
starch intolerance in, 205
treatment of, 205
Illness, acute, contraindicating mater-
nal nursing, 7 1
Imitation of parents mistaken for he-
redity, 360
strong, in child, 360
Immunity, duration of, insured by diph-
theria antitoxin, 308
Imperial granum -water, 119
formula for making, 124
Impetigo contagiosa, 408
Inadequate diet of second year, 56
Inanition and death-rate, 80
fever comphcating sepsis of newly
born, 49
Incisor teeth, time of appearing, 35
Incontinence of feces, 218
of urine, causes of, 338
in cystitis, 351
Incontinence of urine, treatment of,
338, 339
when abnormal, 336
Incubators, baby, defective air-supply
in, 45
Indicanuria in persistent headache, 359
not always present in intestinal indi-
gestion, 162
Indigestion, acute intestinal, 160, 161
onset of, 160
resuming milk in, 161
stopping milk in, 161
treatment of, 161
as cause of anemia, 438
of night-terrors, 365
of urticaria, 407
associated with angioneurotic edema,
388
with pharyngitis, 236
gastric, acute, 177
causes of, 177
treatment of, 177
intestinal, predisposing to diarrhea in
summer, 160
predisposing to acute intestinal in-
fection, 197
Individual, treatment of, 42
Indoor airing, 37, 58, 147
Infantile atrophy, 151
convulsions common in rickets, 441.
See also Convulsions, infantile.
Infectious diseases causing vomiting,
176
Inflation of lungs in asphyxia, 48
Influenza, 452
as cause of endocarditis, 290
danger of complications in, 452
disinfection after, 454
preceding otitis, 418
treatment of, 452, 453
Inguinal adenitis, 424
hernia, 395
reduction of, 395. See also Her-
nia, inguinal.
Inhalation of irritating gases, 254
of steam a cause of laryngitis, 253
Inhalations in asthma, 265
in bronchitis, 258
in bronchopneumonia, 268
in diphtheria, 309
in pertussis, 328
Initial loss in weight, 31
Institutions a factor in artificial feed-
ing, 80
for epileptics, 372
for mentally defective, 383
Instructions for mothers, 92
Insufflations in pertussis, 324
Insufflator for spreading dusting-pow-
der, 357
Intercostal neuralgia, iodin in, 494
Intermittent treatment in chlorosis,
441
58i
Intermittent treatment in chorea, 369
in pertussis, 327
in recurrent broncliitis, 262
in syphilis, with iodids, 392
Intertrigo, 403
Intestinal antiseptics in typhoid fever,
458
diseases, acute, effect of chmate on,
500
etiology of, 187
prevention of, 186
treatment of, 190
hemorrhage rare in typhoid fever, 461
infection a cause of obscure eleva-
tion of temperature, 479
acute, 197
active type, 197
inactive type, 197
treatment of, 197
obstruction, 209, 210
causing vomiting, 176
parasites, 214-216
perforation in typhoid fever, 461
putrefaction as cause of colic, 164
toxemia, headache in, 359
in asthma, 266
in chronic eczema, 404
in epilepsy, 372
Tntraspinous injection of drugs, 377
Intubation, 310
in catarrhal croup, 246
in diphtheria, 312
in edema of larynx, 312
in foreign bodies, 254
in pharyngitis, 314
in retropharyngeal abscess, 314
indications for, 311
method, 31 1
plugging tube with membrane, 314
results from, 313
with use of antitoxin, 314
Intussusception, 211
causing intestinal obstruction, 29
mortality of, 211
reduction of, 211
stools in, 211
Inunctions of cacao-butter, 139
of goose oil, 139
of ichthyol ointment in chicken-pox,
333
of lard, 139
of mercurial ointment, 389
of olive oil, 139
Inverting patient in laryngismus strid-
ulus, 252
lodid of potash, administration, 503
in erythema nodosum, 409
in hydrocele, 356
in multiple neuritis, 382
in peliosis rheumatica, 469
in pleurisy, 280
in poliomyeUtis, 378
unpalatable, 503
Iodids, 392
lodin as counterirritant, 493
in intercostal neuralgia, 494
in pleurisy, 280
in ringworm, 416
of scalj), 415
injection in spina bifida, 397
Ipecac, administration of, 503
in bronchitis, 260
in catarrhal laryngitis, 248
in faucitis, 236
in pneumonia, 270
syrup of, 264
unpalatable, 503
wine of, 325
Iron and ammonium citrate, 367, 440
and qutnin citrate, 126, 159, 164,
287, 288, 439
chloride, tincture of, administration
of, 504
in incontinence of feces, .219
citrate, 439, 440
content of foods, table of, by Bunge,
439
extractum ferri pomatum, 287, 371,
430
in anemia, 440
in cardiac disease, 298
in chlorosis, 441
in hysteria, 362
in neuritis, 382
in persistent adenitis, 425
in poor appetite, 126
in tetany, 367
in tuberculous adenitis, 430
iodid of, in malnutrition of syphih-
tic origin, 393
Irrigation of throat, 245, 319
in diphtheria, 309
in peritonsillar abscess, 245
in quinsy, 241
in scarlet fever, 245
in tonsiUitis, 238
Irritants a cause of gastritis, 177
Ischiorectal abscess, 218
Isolation of sick, 300
Italians and rickets, 441
Itch, 412. See also Scabies.
Itching of anus due to pin-worms, 215
of skin in chicken-pox, 337
Ivy-poisoning, 410
James' tubes for cases of empyema, 280
Jaundice of newlyborn, 50
obstructive, 437
stools in, 437
treatment of, 437
urine in, 437
Jaw deformity due to sucking habit,
432
Jersey cream, percentage of fat in, 83,
107
582
INDEIX
Joint-rheumatism, 463
Junket formula for making, 125
in ileocolitis, 205
in illness, 134
when allowed, 131
Kaolin, cataplasm of, 319, 424
Key-note position, 525
Kidney, sarcoma of, a cause of intesti-
nal olDstruction, 210
Kilmer belt for whooping-cough, 328
croup-kettle, 347, 499
Kindergarten chair, 510
King, experiments on milk contamina-
tion, 100
Kissing, a bad practice, 28
in congenital syphilis, 389
transmission of disease by, 28
Klebs-Loffler bacillus causing diph-
theria, 302
Knee-jerks, increased, in intestinal
toxemia, 163
Knotted towel to insure sleeping on
side, 340
Kyphosis, exercises for, 518
rachitic, 444
Laboratory feeding, 89
Laborde's method of artificial respira-
tion, 48
Lactalbumin of cow's milk, 99
Ladder exercises for ataxic children,
535
Lakewood for convalescent patients,
500
Lamb chop, when allowed, 130
Lancing gums for teething, 36
Lanolin, 78
Laparotomy, indications for, in tuber-
culous peritonitis, 469
Lard, 139
inunctions of, 371
in malnutrition, 158
Larkspur in pediculi, 414
Laryngismus stridulus, 251
adenoids in, 251
diagnosis of, 251
in lymphatic diathesis, 449
in rickets, 251
treatment of, 252, 253
Laryngitis, acute catarrhal, 246
intubation in, 310
membranous, 304
traumatic, 253
Larynx, abscess of, in diphtheria, 244
foreign bodies in, 254
obstruction of, 254
post-diphtheritic paralysis of, 379
removal of foreign bodies from, 254
Late teething, 36
Lavage, 180
amount of fluid to be used, 181
Lavage, dangers of, 180
frequency, 180
in dilatation of the stomach, 184
in gastritis, 179
in gastro-intestinal infection, 191,
192
in marasmus, 153
in poor appetite, 182
in repeated vomiting, 177
in sugar-indigestion, 95
indications for, 180
method of, 180
rarity of its causing bleeding, 185
Laxatives after diarrhea, 197
Lead and opium wash in antitoxin urti-
caria, 307
in erythema nodosum, 409
in orchitis, 356
in rheumatism, 467
neuritis, 381
Leaking breasts, 77
Leg-rubl)ing, 433. See also Mastur-
bation.
Legume diet, 285
Lemonade in typhoid fever, 457
Leukemia, 438
Leukocytosis in diphtheria, 307
in fatal cases of diphtheria, 307
Lice, 413
Lime-water, 70
Lips, fissures of, 226
Lithemic diathesis and asthma, 263
Low fluids in weaning, 7 1
milk diet for intestinal indigestion,
163
Lumbar puncture, 376
disinfection before, 376
in diagnosis 374
in treatment, 374
method of doing, 376
site for, 376
Lymphatic glands, enlarged, in diph-
theria, 237
in tonsillitis, 237
Magnesia in bottle-fed, 169, 170
in chronic ileocolitis, 205
in colic, 166
in fissure of anus, 2 1 4
in glandular fever, 471
Magnesium citrate in acute endocardi-
tis, 291
in appendicitis, 211
in mastitis, 52
in typhoid fever, 458
Malaria as cause of multiple neuritis,
381
blood in, 454
diagnosis often made in intestinal
toxemia, 162
in delicate child, 143
Plasmodium of, 454
INDEX
583
Malaria, (|uinin in, 455
recurrence in, 466
spleen in, 454
temperature in, 454
Male fern, oleoresin of, in tape-worm,
216
Malignant disease contraindicating
nursing, 71
Malnutrition after pertussis, 323
as cause of chronic rhinitis, 222
due to exclusive milk diet, 129
to ileocolitis, 204
to stomatitis, 222
from cutting down proteid in consti-
pation, 169
gavage in, 137
in infants, 156
tardy, non-syphilitic, 158
of syphilitic origin, 392
years to get results in, 18
Malt in tuberculous adenitis, 430
soup, 98, 157
Malted foods a cause of malnutrition,
157
milk in constipation of nurslings, 168,
169
in fissure of anus, 214
in intestinal indigestion, 164
in mucous colitis, 207
with cocoa, 1 72
Maltose, 118
foods only carbohydrates, 118
Mammary abscess, 52
due to cracked nipples, 79
in infants, 52
Marasmus, 150
due to chronic gastritis, 179
in tenements 151
Massage for constipation, 169
in Erb's paralysis, 386
in hematoma of the sternomastoid,
398
in multiple neuritis, 383
in poliomyelitis, 379
of abdomen to relieve intestinal ob-
struction, 210
of breasts, 71, 78
Mastitis, acute, 79
a contraindication to nursing, 79
in newly-born, 52
in young girls, 52
treatment of, 79
Mastoiditis, 423
Masturbation, 433
brace for, 434
circumcision for, 434
cure of, 434
due to leg rubbing, 434
to neurotic habit, 433
to phimosis, 433
to urine being acid, 433
more frequent in girls, 433
night watch in, 435
Maternal nursing, 62. See also Nurs-
ing mother.
ability more frequent nowadays,
62
advantages of regularity in, 66
after twelve months, 70
air and exercise in, 66
amount jjnjper for nursing, 68
bad effect of too long continued,
129
beginning bottles in, 66
best age for, 64
bowel function in, 65
care, of nipples in, 72
conditions forbidding, 71
defmite times for, 43
diet in, 64
feasible duration of lactation, 63
frec|uency of, 73
interfered with, by rhinitis, 229
length of time for each nursing, 68
management of abnormal milk
conditions, 69, 70
menstruation in, 71
mixed feeding, 70
prevented by stomatitis, 221
regularity in, 66
signs of successful, 67
of unsuccessful, 67
temporary discontinuance of, 71
too rapid, 69
too weak milk in, 69
unfavorable factors for, 71
water before, in fever, 133
weaning, 71
Matzoon in typhoid fever, 451
Meals, definite times for, 43
number of, in second year, 172
Measles, 330-332
care of ears in, 332
of eyes in, 33,^
cause of otitis, 418
clothing in, 331
cough in, 332
danger of bronchopneumonia in, 330
death-rate in, 330
delayed rash in, 331
diet 'in, 332
examination of ears in, 332
frequency of, 330
fresh air in, 330
German, 333
in institutions, 330
inunction in, 331
moist air in, 332
old-fashioned treatment of, 330
percentages of susceptibility in, 323
quarantine in, 332
rhinitis of, 230
treatment of, 331, 332
Meat eating in chorea, 368
in chronic diffuse nephritis, 348
in rheumatism, 464
584
Meckel's diverticulum a cause of intes-
tinal obstruction, 210
Mellin's food in constipation, 168, 170
in fissure of anus, 2 1 4
Membrana tynipani, examination of,
in earache, 418
paracentesis of, 480
Meningitis, convulsions in onset of, 363
epidemic cerebrospinal, 373
prognosis in, 373
recovery from, 374
simple acute, 373
tubercular, 373
Menstruation and maternal nursing, 71
Menthol hniment for urticaria, 408
in articular rheumatism, 467
in erythema multiforme, 410
in ointment for eczema, 405
in rhinitis, 230
Mercurv, 392
administration of, 389, 390, 391, 392
albuminate of, 389
bichloride of, 389
salicylate, 389
supplementing interval treatment,
391
Method, necessity of, in care of child,
42
Micturition, first, 335
difficult and painful, 336
Mid-day nap, 43
for delicate children, 149
for nursing mother, 66
in cure of hysterical children, 362
in tardy malnutrition, 158
Miliaria, 416
Milk, a cause of constipation, 169, 171
a factor in acute intestinal diseases,
188
action of, on stomach secretions, 61
certified, 103
contaminated by cow's udder and
body, 101
by manure, 99
by openings in pails, 101
by pouring, 100
by standing, 100
by utensils, 100
cooked, a cause of constipation, 169
cow's, 98-107
adaptation of, 81
by alkalies, 95
by cereal gruels, 97
by malt soup extract, 98
by peptonizing, 97
by sodium citrate, 96
by whey feeding, 96
bottled, 103
care after sterilizing and pasteuriz-
ing, 112
casein of, a cause of intolerance
for, 108
cooHng, 106
Milk, cow's, cost of producing clean,
103
curds of, 96, 97
effect of alkalies on, 61
of cereal gruels on, 97
of peptonizing on, 97
of sodium citrate on, 96
of sterilization on. 111
fat of, adaptation of, 95
affected by cow's diet, 98
child's digestive capacity for, 95
percentage of, compared to that
of human milk, 81
modification of, 82
lactalbumin of, 99
eft'ect of sterilization on, 1 1 1
lactose of, 98
modification of, 82
lime salts, effect of sterilization on,
111
mixtures, resuming, after con-
densed milk, 108
with cream, 84, 85
modification of, 82
by cream and milk mixtures, 84,
85
by dilution, 82
and adding lactose, 83
by laboratory methods, 89
by top-milk methods, 87
by skimmed milk mixtures, 85
peptonization of, 115, 116
proteid of, a cause of colic, 165
adaptation of, 95
reasons for using, in artificial feed-
ing, 81
skimmed, a substitute for whole
milk in fat incapacity, 145
in rectal feeding, 141
mixtures of, 85
solids of, 98
crusts, 405
dairy, percentage value of, 81
diet, exclusive, 128
in nephritis, 343
in scarlet fever, 315
drinking excessive, cause of loss of
appetite, 125
examination in breast fed, 68
food constituents of, 61
for traveling, 1 16
general properties of, 61
habit, 145
and loss of appetite, 126
and malnutrition, 126
herd, 98
human, composition of, 75
affected by sore nipples, 78
exact reproduction of impossible^
56
examination of, 75
fat of, 75
microscopic examination of, 76
INDEX
585
Milk, human, percentage composition
of, 81, 117
percentages of food constituents
of, 75
importance of, in diet of child, 144
in acute intestinal infection, 199
in diet of the nursing mother, 65
in ileocolitis, 197, 200
in mucous colitis, 207
in nephritis, 348
in tetany, 366
in urticaria, 408
malted. See Malted milk.
market, 188
standards of, 102
unsafe in summer, 188
maximum amount of, after first
year, 145
raw, in constipation, 169
resuming, after diarrhea, 161, 196
selected, 188
stopping, in acute intestinal infec-
tion, 197
supply in country, 492
to be avoided in tvphoid fever, 457
Milking, directions for, 189
Minced beef, when allowed, 130
Mineral substances in foods, function
of, 60
Mixed feeding, 70
in wet-nursed babies, 74
infections of throat, 237
treatment, 392
Modern school system, pernicious, 58
Modified milk, definition of, 81
Moist air in care of measles, 332
skin predisposing to colds, 228
Molar teeth, time of appearance of, 35
Molasses and water injection for fecal
impaction, 260
Mongolian idiot, 385
Morphin in acute gastro-intestinal in-
fection, 192
in convulsions, 364
in cyclic vomiting, 472
in meningitis, 375
in pronounced vomiting, 1 79
unnecessary in asthma, 265
with atropine, ratio of doses, 179
Mortality from summer diseases, 160
statistics valueless in regard to nu-
tritional errors, 80
Mosher's kindergarten chair, 510
Mother, education of, 17, 21, 161
ignorance of, due to physician, 43
nursing. See \ursing mother.
Mountains, 492
Mouth breathing due to adenoids, 426
to hypertrophied tonsils, 239
portal of entry of pyogenic bacteria,
49
temperature in children, 475
toilet, 221, 222
Mucous colitis, 206
diet in, 206
stools in, 206
Multiple neuritis due to arsenic, 381
to exanthemata, 381
to lead, 381
to malaria, 381
to phosphorus, 381
Mumps, 334
complicated with nephritis, 334
a rare cause of deafness, 422
with orchitis, 355
Muscular twitchings in acute intestinal
infection, 199
Musk as a heart stimulant, 277
Mustard as a counterirritant, 493
baths, 30, 260, 268, 269, 363
leaves, 178
plasters, 259, 265, 269, 280
Mutton broth, formula for preparing,
123
Myocarditis, 294
after diphtheria, 379
endocarditis, 293
pneumonia, 293
scarlet fever, 293
diet in, 294
rest in, 295
sitting up after, 295
stimulation in, 294
Myxedema, infantile, 445
Napkin washer, 20
Nasal discharge, chronic, due to ade-
noids, 426
hemorrhage due to adenoids, 234
to ulcerations of nasal septum,
234
treatment of, 234
Nasopharynx, inflammation of, as
cause of asthma, 263
Negro, rickets in, 441
Nephritis, acute, bathing in, 344
bowel function in, 344
colon flushing in, 346
diet in, 344
hot packs in, 346
treatment of, 343-345
urea in, 347
uremic convulsions in, 347
chronic diffuse, 348
baths in, 348
beef foods in, 129
climate in, 349
clothing in, 349
diet in,' 348
exercise in, 349
headache in, 359
in mumps, 334
interstitial, 349
maternal nursing contraindi-
cated by, 71
586
Nephritis, chronic diffuse, rare under
three years, 348
secondary to acute, 348
vomiting caused by, 176
post-scarlatinal, 321
Nerve grafting, 387
Nervous cough, 255
disorders of childhood, 162
Nettle-rash, 407
Neurasthenia diminishing among wo-
men, 62
Neuritis, multiple, 381
Neurotic eczema, 404
New Mexico for tuberculosis, 501
New York County Medical Society,
Milk Commission of, 103
Newly born, affections of, 45-55
asphyxia of, 48
atelectasis of, 51
cephalhematoma of, 50
granuloma of, 53
hemorrhagic diseases, 53
jaundice in, 50
mastitis in, 52
sepsis in, 49
tetanus of, 54
time for first bath in, 29
umbihcal polyp of, "51
Night bottle, 88
breaking from, 88
terrors, 365
watch in masturbation, 436
Nipple, care of, 23, 72
cracked and fissured, 77
depressed, 79
shield in cracked nipples, 78, 79
Nitrate of potash in asthma of older
children, 265
Nitre, sweet spirits of, in cough of
measles, 332
Nitric acid in noma, 225
in pertussis, 325
Nitrogenous food in acid urine, 338
Nitroglycerin contraindicated in myo-
carditis, 295
in cyanosis, 271, 276
Nitrous oxid gas and ether in ade-
noids, 428
danger signals in administra-
tion, 495
under two years to be used with
caution, 495
with caution, 495
Noma, 224
Nose, portal of entry of pyogenic bac-
teria, 49
Nursery, airing of, 24
changing napkins in, 24
floor of, 24
fresh air in, 25
maid, gonorrhea in, 23
physical examination, 23
schools for training, 23
Nursery maid, tuberculosis in, 23
requirements of, 24, 25
shades for, 25
steam heat in, 25
sweeping in, 24
temperature of, 147
ventilation of, 24
Nursing. See Klaternal nursing.
bottle, care of, 23
mother, amount of food necessarv
for, 65
constipation in, a cause of colic in
child, 165
diet of, 64
mid-day rest for, 66
rules for, 64
requirements of, 23
Nutrient enema, 115, 141
in cyclic vomiting, 472
in persistent hematemesis, 185
in post-diphtheritic paralysis, 381
suppositories, 138
Nutrition a factor in treatment of tub-
erculosis, 285
and growth, 55-155
defective, a cause of many deaths, 80
important in tuberculous peritonitis,
469
Nutritional disorders of childhood, in-
digestion a factor in, 162
Nux vomica, tincture of, 66, 126, 437,
441, 458
in constipation, 164, 174
in malnutrition of syphilitic
origin, 393
in mucous colitis, 207
in tardy malnutrition, 159
in tuberculosis, 287
Nystagmus associated with gyrospasm,
366
Oatmeal, 145
a cause of urticaria, 407
gruel in the cure of constipation, 171
when allowed, 130
jelly, 129
formula for preparing, 123
water, formula for preparing, 124
in constipation of bottle fed, 169
when allowed as a cereal, 130
Obesity, diet in, 438
Obstetrical paralysis, 386
O'Dwyer, Joseph, M. D., inventor of
intubation, 310
Oil injections in constipation of bottle
fed, 70
in malnutrition of infants, 158
in prolapse of rectum, 217
inunctions in chronic ileocolitis, 206
in marasmus, 156
in measles, 331
in scarlet fever, 317
587
Oil of cade in collodion, 402
of wintergreen in rheumatism, 467
treatment for constipation, 159, 164,
168, 174, 262, 372
Oiled silk jacket, 267, 274
Ointments in cracked nijjplcs, 78
in eczema, 403
Oleoresin of male fern in tai)c-worm,
216
Oleum phosphoratum in rickets, 444
Olive oil in constipation, 170
in contagious impetigo, 408
in mucous colitis, 206
in seborrhea capitis, 406
rub, 139, 146
Omelet, when allowed, 131
Open windows a cause of catching
cold, 229
Operation for appendicitis, 211
for bow-legs, 444
for cleft-palate, 398
for hare-lip, time of, 398
for pyloric stenosis, 186
for rectal prolapse, 217
for spina bifida, 397
for tuberculous adenitis, 430
for umbilical hernia, 396
Opium and its derivatives in diabetes,
357
contraindicated in colic 166
in diarrhea, 193
of typhoid, 458
in gastric indigestion, 1 79
in hysteria, 362
in ileocolitis, 201
narcosis, gavage in, 137
Optical delusions in intestinal toxemia,
163
Orange juice in constipation of bottle-
fed, 170
in scurvy, 445
Oranges, when allowed, 131
Orbicularis oris, hypertrophy due to
thumb-sucking, 432
Orchitis complicating nmmps, 334,
355
Otitis media, 418
a cause of facial paralysis, 383
of obscure elevation of temper-
ature, 479
of persistent deafness, 422
danger of, from throat irriga-
tions, 309
in influenza, 453
in measles, 332
in scarlet fever, 319
suppurative, 422
Outdoor exercise after pleurisy, 280
Outdoors, going out, 37, 147
Overeating as cause of dilatation of
stomach, 183
of vomiting, 176
during second year, 128
Overeating, effect of, on milk, 69, 127
in nurslings, 69
Overwork in exercises, 57
Oxygen in atelectasis, 52
in pneumonia, 272
Oxyuris vermicuiaris, 215
Pacitier, 432
Packs. vSee Cool pack.
Pad for umbiHcal hernia, 396
Pain a symptom of pleurisy, 278
counterirritants for, 493
in chest, often absent in lobar pneu-
monia, 273
in otitis, 419
in peritonitis, 469
Pancreas, starch -converting enzyme
of, 122
Paper napkin for tuberculosis sputum,
287
Paracentesis of membrana tympani
in ciironic otitis media, 422
indication for, 420
Paralysis, Erb's obstetrical, 386
infantile, 378
of larynx after diphtheria, 379
of pharynx after diphtheria, 379
Paraphimosis, treatment of, 354
Paraplegia, 384
Parasiticide for ringworm of the scalp,
415
Paregoric, 201, 289, 332
Park, Dr. William Hallock, experi-
ment in summer diarrhea, 189
Parotitis, epidemic, 334. See also
Mumps.
Parsons on bacteria and cow's milk, 99
Pasteurization of milk, 1 1 1
Patent medicines, 502
Patient, first examination of, 39
Pavor diurnum of intestinal origin,
162
Peaches, when allowed, 132
Pears, when allowed, 131
Peas, when allowed, 131, 145
Pediculi, treatment of, 413, 414
Peliosis rheumatica, 468
Pemphigus due to syphilis, 469
neonatorum, 408
Peppermint water as a vehicle, 504
Pepsin, essence of, for making junket,
125
whey, 125
in stomach of young child, 61
Peptonized milk, 115
in adaptation, 97
in diflficult feeding, 108
in gavage, 137
in rectal feeding, 140
in tetany, 367
processes, 1 1 5
Peptonizing tubes, 116
588
INDEX
Percentage composition of foods, 60
Perforating ulcer of stomach, rarity of,
184
Pericarditis as cause of pleurisy, 279
due to rheumatism, 289
rheumatic, treatment of, 290
Pericardium, incision of, 290
Pericranial hemorrhage in newly born,
54
Perimastoiditis as sign of mastoiditis,
423
Periodic temperature in empyema, 454
in fatigue, 454
in influenza, 454
in intestinal infection, 454
in malaria, 454
not due to malaria, but cured by
quinin, 479
Periostitis of tibia, syphilitic, 391
Peristalsis, visible, in tuberculous peri-
tonitis, 469
Peritonitis, acute general, 469
infective, causing intestinal ob-
struction, 210
tuberculous, 469
causing intestinal obstruction, 209
fever in, 470
rest in bed in, 470
Peritonsillar abscess, 240
irrigation of the throat in, 245
peptonized milk by gavage in, 115
Permanent teeth, order of their appear-
ance, 35
Permanganate of potash in gonor-
rhea, 355
Peroxid of hydrogen in noma, 225
Persistent adenitis, often tubercular,
425
operation on, 425
cough after intubation, 313
due to adenoids, 255
to adherent pleura, 244
vomiting diagnosed as gastritis, 177
due to congenital pyloric stenosis,
186
in acute gastric indigestion, 177
Pertussis, 321
age of occurrence, 322
antipyrin and bromid in, 328
belt for, 328
bronchopneumonia in. 323
catarrhal stage, 327
causing hernia, 375
vomiting, 176
complications of, 323
convulsions in, 323
diagnosis of, early, 323
extravasations of blood in, 324
fresh air in, 328
greatest susceptibility to, 328
incubation period of, 322
malnutrition in, 323
management of, 324
Pertussis, percentage of susceptibility
to, 323
quinin in, 325
season of occurrence, 322
steam inhalations in, 323
transitory deafness in, 323
tuberculosis in, 323
versus laryngismus stridulus, 252
without a whoop, 323
Pharyngitis, 236
Pharynx, post-diphtheritic paralysis
of, 379
Phenacetin, 477
in bronchopneumonia, 270
in influenza, 452
in typhoid fever, 459
Phimosis, 353
as cause of convulsions, 353
causing difficult micturition, 336
incontinence of urine, 338
retention, 337
deterrent to growth, 143
in epileptics, 372
in masturbation, 433
treatment of, 381
Phosphorus as cause of multiple neu-
ritis, 381
Physical examination, frequency of,
in measles, 332
Pin-worms, 215
Plasmodium malaria^, 454
Plaster-of-Paris, 444
Play in chorea, 368
Pleura, adherent, as cause of cough,
255, 256
Pleurisy, acute primary non-rheumatic,
278
dry, 278
iodin in, 494
secondary, 279
tubercular, primary, 280
with effusion of rheumatic origin, 466
of tuberculous origin, 280
Pleuritic adhesions, 280
effusions, 279
pain, counterirritation in, 493
Pneumonia, broncho-, 266-272
bowel function in, 68
complicating influenza, 453
measles, 330
pertussis, 323
diet in, 267
drugs in, 269
fever in, 258
hydrotherapy, 271
hygiene, 267
inhalations, 268
oxygen in, 272
central, 273
lobar, 272-278
alcohol in, 498
as cause of endocarditis, 296
of pleurisy, 279
INDEX
589
Pneumonia, lobar, complicated by
multiple neuritis, 381
convulsions in onset of, 363
crisis in, 273
delayed signs of, 273
hcaciaches in onset of, 359
onset of, 272
physical signs of, 273
treatment of, 278
Podophyllin in cure of constipation, 1 74
Poisoning from impure bismuth, 194
from rhus toxicodendron, 410
Poliomyelitis, acute anterior, 378
drugs in, 379
electricity in, 379
massage in, 379
prevention of deformity, 379
treatment in acute stage, 378
Polyuria, absence of, in glycosuria, 329,
350
Position for defecation in rectal pro-
lapse, 217
Post-cervical glands, enlarged, in Ger-
man measles, 333
Post-diphtheritic paralysis, 379-381
age of occurrence, 378
difficult swallowing in, 379
gavage in, 381
heart action in, 379
irregularity of pulse in, 378
of extremities, 379
of larynx, 379
of pharynx, 379
rectal feeding in, 381
treatment of, 379-381
Postural treatment of rectal prolapse,
217
Posture and breathing, 508
Potassium chlorate in tonsillitis, 239
citrate, 352
in acute pyelitis, 352
in eczema due to hyperacidity, 401
iodid, 391, 392. See also lodid of
potash.
Potato, baked, when allowed, 130
stewed, when allowed, 131
Pott's disease, secondary to tubercu-
lous peritonitis, 470
Poultice, flaxseed, 278
flaxseed and mustard, 278
Poultry, when allowed, 131
Predigested cereals in gavage, 137
foods during illness, 133
in lobar pneumonia, 277
Pregnancy a contraindication to lacta-
tion, 71
Premature infants, 45-47
air for, 45
cause of prematurity and effect on
hfe, 45
feeding of, 47
length of life in, 45
warmth, 45, 46
Prepuce, adherent, treatment of, 352
Prescriptions for laboratory feeding,
90
of exercise, 506
Pressure in hemorrhagic diseases of the
newly born, 54
of water in reduction of intussuscep-
tion, 21
Prevention of intestinal diseases of
summer, 186
Prickly heat in overclad children, 416
starch bath in, 31
Prolapse of rectum, 216
operation for, 2 1 7
treatment of, 217
Proprietary foods as cause of rickets,
442
of scurvy, 445
as sole diet, 57
disadvantages of those not con-
taining milk, 117
dried milk foods, 1 18
standard for selecting, 117
Protection against colds, 149
Proteid content of intestine as cause
of intestinal toxemia, 163
of cow's milk, 98
adaptation of, 94-98
modification of, 82
incapacity as cause of colic, 164
indigestion, signs of, 89, 95
minimum for normal growth, 169
in proprietary foods, 1 1 7
Proteids, essential ingredients of foods,
59
functions of, 60
of milk as cause of colic, 164
where found, 59
Prunes, stewed, when allowed, 130
Pseudoleukemic anemia of von Jaksch,
438
Pseudomembrane in tonsillitis, 237
Puddings, when allowed, 130
Pulse, irregularity of, after diphtheria,
379
in myocarditis, 294
Purees of peas, beans, and lentils,
57
Purpura, causes of, 449
fulminant, 183
in peliosis rheumatica, 468
in pyemia, 449
in septicemia, 450
prognosis in, 450
Putrefactive bacteria and cow's milk,
99
Pyemic infection of nose, 232
Pyloric spasm, 185
stenosis, congenital, 185
as cause of vomiting, 185
operation for, 185
stomach wave in, 185
treatment of, 186
590
INDEX
Quarantine, 300-302
in measles, 332
Quassia, infusion of, in thread-worms,
215
Quiet in sick-room, 317
Quincke needle for lumbar puncture,
376
Quinin bisulphate, 504
administration of, 504
by hypodermic injection, 455
by inunction, 455
by mouth, 455
by rectum, 455
as cause of urticaria, 407
in finger sucking, 432'
in lobar pneumonia, 278
in malaria, 455
in malnutrition of syphiHs, 393
in mucous coHtis, 207
in neuritis, 382
in tuberculosis, 287
in typhoid fever, 459
Quinsy, 240. See Abscess, periton-
sillar.
Rachitis, 441-445. See Rickets.
Raspberry, syrup of, as vehicle, 222,
326
Raw milk vs. sterilized or pasteurized
milk, 112
Records of cases, 39
of daily illness, blank form for, 61
Rectal bleeding suggesting polypus, 219
feeding, 139-141
after acute gastro-intestinal indi-
gestion, 178
in cyclic vomiting, 472
in diphtheria, 310
in meningitis, 375
of peptonized skimmed milk, 115
substances contraindicated in, 140
irrigation in typhoid fever, 460
medication, method of giving, 253
sodium salicylate by, 290
polypus, 219
temperature in child, 475
tube, size for, 208
Rectum, examination of, in constipa-
tion, 170
prolapse of, 216
Recurrence in chorea, 370
Recurrent bronchitis, 261
Red meat as cause of rheumatic at-
tacks, 464
in asthma, 266
in cardiac disease, 296
in habit spasm, 370
in recurrent bronchitis, 262
to increase fat in milk, 167
Reflex eczema, 404
Regurgitation, persistent, 95
Removal from home in chorea, 368
Removal of adenoids in chronic nasal
discharge, 233
in mouth breathing, 233
in nasal hemorrhage, 234
Rennet, essence of, for making junket,
125
Resorcin in pertussis, 324
in seborrhea capitis, 406
Respirations in lobar pneumonia, 273
Rest after gymnastic therapeutics, 507
in acute endocarditis, 291
in anemia, 439
in chorea, 367
in diphtheritic paralysis, 380
Restlessness in broncho-pneumonia,
270
Results in pediatrics often delayed, 18
Retention of urine, 336, 337
Retropharyngeal abscess, 242
adenitis, 242, 429
due to caries of cervical vertebrae,
245
gavage in, 115
intubation in, 310
irrigation of throat in, 245
Revaccination, 485
I Rheumatic diathesis, 239, 463
in hypertrophy of tonsils, 239
family history in cardiac disease, 296
pain, chloroform liniment in, 494
pleurisy, 279, 466
Rheumatism a factor in asthma, 263
in chorea, 367
j in cychc vomiting, 472
as cause of endocarditis, 290
of erythema nodosum, 401
I of multiple neuritis, 383
j of recurrent bronchitis, 464
j growing pains due to, 463
j importance of, in family history, 39
in habit spasm, 370
joint pains due to, 463
management of case of, 464
occurrence of, 463
oil inunctions in, 138
pleurisy due to, 466
red meat in, 464
sugar in, 464
tonsillitis in, 463
treatment of, local, 467
between attacks, 467
underlying recurrent bronchitis, 262
Rhinitis, acute, as cause of chronic
rhinitis, 272
in onset of measles, 230
interferes with nursing, 229
of congenital syphilis, 390
versus diphtheria, nasal, 230
rhinitis, syphilitic, 230
Rhubarb and calomel in pharyngitis,
236
and soda in chronic eczema, 404
in faucitis, 236
INDEX
591
Rhubarb and soda in intestinal indiges-
tion, 164
in jaundice, 437
Rhus toxicodendron, poisoning from,
410
Rice as cereal, when allowed, 130
water after gastro-intestinal infec-
tion, 192
formula for making, 124
Rickets, 441-445
a cause of laryngismus, 251
and infant mortality, 441
due to steriHzation of milk, 1 1 1
in gyrospasm, 366
in infantile convulsions, 441
in laryngismus stridulus, 251, 441
kyphosis, 444
predisposing to catching colds, 229,
441
to convulsions, 363
Ringworm, 416
of scalp, 414, 415
Roast beef, when allowed, 131
Rochelle salts in caked breasts, 71
Roof gardens, 147
Rosary, rachitic, 441
Round-worms, 214
Rubbing through teeth, 36
Rubella, 333. See also German meas-
les.
Rules for care of infants at New York
Babies' Hospital Dispensary, 92, 489
Saccharin as substitute for sugar in
rheumatism, 464
in cure of obesity, 438
in place of sugar in asthma, 266
Salicylate of soda, administration of,
503
by rectum, 290
an unpalatable drug, 502
dangers of, 19
dosage of, 464
in antitoxin urticaria, 307
in asthma, 266
in cardiac disease, 296
in chorea, 368
in cyclic vomiting, 473
in endocarditis, 291, 292
in erythema multiforme, 410
in habit spasm, 371
in influenza, 452
in meningitis, 375
in multiple neuritis, 382
in pericarditis, 290
in pneumonia, lobar, 278
in recurrent bronchitis, 261 262
in urticaria, 408
nausea and vomiting from, 467
Salicylic acid in dusting powder,
53
with tar locally in eczema, 405
Saline enema in sepsis of newly born, 50
solution, normal, in cok)n flushing,
496
Salivation in stomatitis, 220
Salt bath, 146
during illness, 483
in chroijic ileocolitis, 206
in habit spasm, 371
water fcjr sponging, 480
Sanitarium treatment, advantages of,,
501
for tuberculosis, danger of, 501
Santonin in worms, 214, 215
Sarsaparilla, 134
Scabies, 412
Scales for weighing, 33
Scarification in erysipelas, 461
vScarlatina, 314-321
as cause of endocarditis, 290
of general peritonitis, 469
of otitis, 418
clothing during, 315
compHcated by adenitis, 319
by arthritis, 321
by deafness, 320
by nephritis, 321
by neuritis, multiple, 381
by otitis, 320
convulsions in onset of, 363
death rate in, 314
desquamation in, 318
diet in, 315, 316
fever in, 317
headache in onset of, 359
irrigation of throat in, 245
laxatives in, 316
management of, 314
serum treatment of, 317
sick-room in, 315
urine examination in, 315
with myocarditis, 293
Scarlatinal nephritis, 348
Scars from chicken-pox, 333
School children, diet suitable for, 57
for delicate children, 149
hygiene, 512
in chorea, 368
in habit spasm, 371
in malnutrition, 158
Schultze's method for artificial respira-
tion, 48
Scoliosis, 521
Scorbutus, 445. See also Scurvy.
Scraped beef, 145
formula for preparing, 123
in chronic ileocohtis, 205
in typhoid fever, 457
when allowed, 129
Scurvy due to proprietary foods, 1 1 8
to sterilization of milk, 1 1 1
orange-juice in, 445
Seashore, 147
aggravating catarrh, 492
592
INDEX
Seashore in asthma, 501
Season as factor in artificial feeding, 93
in marasmus, 153
Seborrhea capitis, 405
intertrigo, 406
Seidlitz powder, 291
Separation from family in hysteria, 337
Sepsis in newly born as a cause of hemor-
rhagic disease, 54
location of process, 49
portal of entry of, 49
treatment of, 49
Serum treatment of diphtheria, 302
of scarlet fever, 316
Shampoo of ohve oil and kerosene, 415
Sherry wine, 126
in marasmus, 153
in tuberculosis, 287
Showing off, pernicious, 362
Sick-room, 43
in bronchopneumonia, 267
in grippe, 454
in lobar pneumonia, 274
in measles, 331
in scarlatina, 315
Silver nitrate in cord-stump, 26
in cracked nipples, 78
in fissure of anus, 214
of the lips, 226
in granuloma, 53
in ulcer of frenum of tongue, 226
Sitting, posture in, 508
up, time for, 26
Skimmed milk in acute intestinal indi-
gestion, 166
in convalescence from ileocolitis,
203
chronic, 205
in obesity, 438
in recovery from diarrhea, 194
in rectal feeding, 141
mixtures, 85
pancreatized, in enemata, 140
percentage equivalents of, 85
Skin as portal of entry for pyogenic
bacteria, 49
care of, in chicken-pox, 333
diseases of, 400-417
irritant lesions, in epilepsy, 372
lesions affecting growth, 143
Sleep, amount of, necessary, 27
disturbed, causes of, 28
induced by mustard-baths, 30
talking in, due to intestinal toxe-
mia, 163
Sleeping alone, 25
late, 159
posture for, 509
rooms for delicate children, 147
Sleeplessness in pertussis, 327
Snuffles, 230
•Soap, kitchen, for ringworm of scalp,
414
Soapsuds enema. See Enema.
Soda bath, 3 1
in eczema, 403
in prickly heat, 416
mint in colic, 166
Sodium biborate in angioneurotic
edema, 388
in tonsillitis, 238
bicarbonate in grippe, 452
bromid. See Bromid of soda.
carbonate, solution of, for diapers, 29
citrate, 96, 108
sulphate in acute gastro-intestinal
infection, 192, 197
Soft-boiled eggs in typhoid fever, 457
Soiled napkins, care of, 25
Sore mouth, 221. See also Stomatitis.
Soups, when allowed, 131
Spasm, habit, 370
Spasmus nutans, 365
Spina bifida, 397
Spinach, when first allowed, 130
Spinal ataxia, exercises for, 527
canal, injection of drugs into, 375
douche, 146
in recurrent bronchitis, 263
Spirit of mindererus, 476
Sphnts after anterior poliomyelitis, 379
in dactylitis, 470
Spoiling a sick child, 317
Sponge bath in diphtheria, 310
in fever, 476
in lobar pneumonia, 275
in measles, 331
in mumps, 334
in scarlet fever, 481
in summer, 487
never to be used on a baby, 29
Sprays, 309
of alijolene and menthol for rhinitis,
230
Spring water, 492
Sprue, 223
Square head, 441
St. Vitus' dance, 367. See also Chorea.
Standard of milk for infant feeding, 103
Staphylococcus albus in pemphigus,
409
Starch, addition of, to food, beginning,
128
bath, 31
in prickly heat, 418
digestion, in young infants, 120, 121
feeding, 121-123
in ileocolitis, 205
and opium enema in ileocolitis, 203
Starvation treatment of vomiting, 178
Status lymphaticus, 449
Steak, when allowed, 131
Steam inhalation, 258
in bronchitis, 258
in bronchopneumonia, 258, 268
in catarrhal croup, 249
595
Steam inhalation in pertussis, ^25
Sterilization of milk, effect of, 111
in feeding dispensary patients, 93,
111
methods of, 1 1 1
Sterilized milk as cause of scurvy, 445
Sternomastoid, hematoma of, 398
Stertorous breathing in retropharyn-
geal abscess, 242
Stock gruels, 457
prescriptions, 502
Stomach cough, 255
development of, by milk, 61
feeding, substitutes for, 138
in chronic gastro-enteritis, 184
in newly born, 184
inflammation of, as cause of vomit-
ing, 176
ulcers of, causing hematemesis, 183,
184
vomiting, 176
washing, 180. See also Lavage.
wave in congenital pyloric stenosis,
186
Stomatitis, 220
aphthous, 220
catarrhal, 220
improper care of mouth as cause of,
220
mycotic, 223
treatment of, 222
ulcerative, 220
Stone in bladder, 351
Stools, green, as signal for giving castor
oil, 160
due to high fat, 67
to indigestion, 95
immediate treatment of, 189
in bronchopneumonia, 268
in congenital stenosis of pylorus, 186
in difficult feeding, 108, 109
in fissure of anus, 213
in ileocolitis, 200, 204
in intussusception, 211
in typhoid fever, 458
in unsuccessful maternal nursing, 67
Strapping chest in pleurisy, 278
for ventral hernia, 397
Straus laboratory milk, 188
milk charity, 91
Strawberries as cause of urticaria, 407
Streptococcus causing purpura, 450
throat, cHnically like diphtheria, 303
usually cause of retropharyngeal ab-
scess, 242
String-beans, when allowed, 130
Stringed screen for gymnastic thera-
peutics, 506
Strophanthus, tincture of, abuse of, 299
in bronchopneumonia, 270
in cardiac disease, 299
in diphtheria, 310
in endocarditis, 291
38
I Strophanthus, tincture, in gastro-in-
i testinal infection, 191
I in ileocohtis, 201, 202
in intestinal infectif)n, 199
in lobar pneumonia, 276
in myocarditis, 293
in nephritis, 347
in pericarditis, 289
in postdiphtheritic neuritis, 380
in scarlet fever, 318
in typhoid fever, 460
Striimpell quoted, 368
Strychnin, administration of, 504
after diphtheria, 380
contraindicated in acute intestinal
infection, 199
dosage in myocarditis, 293
in bronchopneumonia, 270
in diphtheria, 310
in enuresis, 342
in lobar pneumonia, 276
in mucous colitis, 207
in neuritis, 382
in scarlet fever, 318
in typhoid fever, 460
Study, amount of, for neurotic children,
361
Stupes, turpentine, in colic, 494
Styptics in hemorrhagic diseases of the
newly born, 54
Substitute feeding, 89. See also
Feeding, artificial.
Sudden death due to myocarditis, 294
to status lymphaticus, 449
Suffocation from foreign bodies in
larynx, 254
Sugar, administration of, causing glyco-
suria, 349
capacity, low, in chronic gastritis, HP'
content of cow's milk, 98
in asthma, 264-266
in cardiac disease, 296
in chorea, 368
in cyclic vomiting, 493
in obesity, 438
indigestion, 94
signs of excess, in food, 95
water, between nursings, 73
Suggestion a factor in children's com-
plaints, 360
Sulphid of calcium in furunculosis,
412
Sulphur in administration of bismuth,
194, 201
in ringworm of scalp, 414
ointment in scabies, 412
Summer, bathing in, 489
care of feeding bottles in, 490
of milk in, 489
clothing in, 489
diarrhea. See Indigestion, acute in-
testinal.
mortahty in, 160
594
INDEX
Summer, fresh air in, 489
instructions for, 487
resorts, 491, 492
for delicate children, 148
sleeping, 489
undigested stools during, 487
Suppositories, 168
in constipation, 170
Suppression of urine, 337
Suppuration of cephalhematoma, 50
of glands, treatment of, 425
Suprarenal extract in persistent hemat-
emesis, 185
in purpura, 450
Suspensory bandage after orchitis, 156
Swallowing, difficulty, after diphtheria,
380
due to retropharyngeal abscess,
242
Sweating for control of fever, 476
Syphilis as cause of cerebral palsy,
383
of fissures at angle of mouth, 226
congenital, 389-391
epitrochlear glands in, 390
inunctions of mercuric ointment
in, 389
iodid of potash in, 392
later treatment of 389-391
rash of, 390
contraindicating maternal nursing,
71
hereditary transmission of, 431
hoarseness in, 390
importance of, in family history, 39
oil inunctions in, 138
tardy hereditary, 391, 392
malnutrition an evidence of, 392
transmitted by kissing, 28
with hemorrhagic diseases of newly
bom, 54
SyphiUtic dactyhtis, 470
periostitis of tibia, 391
Syrups for children, 269
upsetting indigestion, 19
Table, adjustable, for children, 509
of weights and heights, 32
Taenia, 215
Taking cold, 228
Tannalbin in ileocolitis, 202
Tannic acid for blood in stools, 208
for hemorrhoids, 218
Tape for restraint in masturbation, 436
Tape -worm, 216
Tar and salicylic acid in chronic eczema,
405
ointment of, in eczema, 403
Tardy malnutrition, regimen to be fol-
lowed, 159
Tartar emetic, administration, 503
in acute catarrhal laryngitis, 249
Tartar emetic in bronchitis, 260
in bronchopneumonia, 269
in faucitis, 236
unpalatable, 503
Tastes, 129
Tasting, 132
Taylor, Dr. A. S., operations for cure of
hydrocephalus, 377
Tea after sixth year, 132
constipating for nursing mothers, 66
drinking as cause of constipation, 167
in typhoid fever, 457
Teeth, care of, 35
cavities in, 35
first tooth to appear, 35
in rickets, 441
loss of first, 35
presence of, necessary for ulcerative
stomatitis, 220
Teething cough, 225
Temperature, abnormal rise of, 475
birth, 474
by what to reduce, 270, 271
effect of antitoxin on, in diphtheria,
304
in earache, 418
in gastro-intestinal infection 190
in influenza, 452
in lobar pneumonia, 273
in marasmus, 152
normal, 474
obscure elevations of, 477-479
caused by encysted empyema,
479
by exercise, 477
by intestinal infection, 479
by otitis, 479
by tuberculosis, 479
by typhoid fever, 479
of dressing-room, 229
of sick-room, 267, 274
periodic, in malaria, 454
reduction of, when to reduce, 271
subnormal, by axilla, 475
by mouth, 475
by rectum, 475
in cretins, 446
in measles, 332
unexplained, 480
when to interfere with, 476
Tendon-transplantation after polio-
myeUtis, 379
Tenesmus, 202
Tenotomy after poliomyehtis, 379
I Tetanus antitoxin, 54
neonatorum, 54
Tetany, 366
Therapeutic nihihsm, 18
Thermometers in nursery, 25
Thickened lips due to use of pacifier, 432
Thirst, absence of, in glycosuria, 349
: Thoracotomy for double empyema, 284
1 in empyema, 282
INDEX
595
Thread-worm, 215
and masturbation, 433
as cause of enuresis, 378
in night-terrors, 365
Throat, examination of, 234
Thrush, 223
Thumb sucking, 432
results of, 432
Thymic asthma, 449
Thymus, enlarged, and convulsions,
365
Thyroid extract, dosage, 448
evidences of excess of, 447
in cretinism, 447
in obesity, 438
Tinea circinata, 416
tonsurans, 414
Tomatoes as cause of urticaria, 407
stewed, when allowed, 130
Tongue, bridle, 226
swelling of, in angioneurotic edema,
387
traction on, Laborde's method of
artificial respiration, 48
ulcer of frenum of, 226
Tongue-tie, treatment of, 227
Tonsillar punch for hvpertrophied ton-
sils, 240
Tonsillitis associated with cardiac dis-
ease, 292, 296
with rheumatism, 463
diagnosis versus diphtheria, 237
difficulty in swallowing in, 238
duration of, 237
onset of, 236
preceding otitis, 468
quinsy, 240
sprays in, 238
symptoms of, 237
treatment of, 237-239
Tonsils, a cause of persistent deafness,
422
a harboring place for bacteria, 239
hypertrophied, 239 •
in epileptics, 372
in night-terrors, 365
removal of, for chronic bronchitis,
261
with asthma, 263
Tooth picks, 35
powder, 35
Top-milk in cure of constipation of
older children, 1 7 1
Toxemia, intestinal, diagnosed as mala-
ria, 162
as worms, 162
due to defective bowel evacuation,
167
Trachea, cast of, 314
Tracheitis as cause of persistent cough,
255
Tracheotomy for foreign bodies in
larynx, 254
Trauma as cause of cerebral palsy, 383
of early convulsions, 363
Traumatic laryngitis, 253
Trichophyton, 416
Truss, cleaning, 395
in inguinal hernia, 395
in umbilical hernia, 396
in undescended testicle, 356
measuring for, 395
Tub baths for fever, 318, 476
Tubercle bacilli in sputum of children,
285
Tuberculosis as cause of obscure eleva-
tion of temperature, 479
cHmate in, 285
contraindicating maternal nursing,
71
devices for collecting sputum in, 287
fatality in young children, 285
frequency of occurrence, 285
fresh air in, 286
high proteid diet in, 285
home treatment versus sanitarium,
286
importance of, in family history, 39
in bronchiectasis, 288
in delicate child, 143
infiltration of, incipient, a cause of
persistent cough, 256
in marantic cases, 152
in nursery maids, 23
in pertussis, 323
occurrence of, 286
of cervical lymph-glands, 430
of hip-joint, 471
of knee-joint, 471
of spine, 471
oil inunctions in, 138
physical signs of, 285
prognosis in, 287
tenement cases, 287
transmitted by kissing, 28
Tuberculous dactylitis, 470
peritonitis, 469
suppurative, 469
Tumors of intestine causing intestinal
obstruction, 210
Turbinate bones causing nasal catarrh,
232
Turpentine as counterirritant, 493
in bronchoi:)neumonia, 268
in thread-worms, 214
inhalations in pertussis, 325
Tympanites, 458
Typhoid fever, alcohol in, 498
antipyretic drugs in, 460
care of mouth in, 456
cervical adenitis in, 457
diarrhea in, 459
diet in, 457, 458
disinfection of excreta in, 457
gingivitis in, 457
heart stimulants in, 460
596
INDEX
Typhoid fever, hemorrhage in, 461
hydrotherapy in, 460
intestinal antiseptics in, 458
milk in, 457
perforation in, 461
rarity of, in children, 456
rectal irrigations in, 460
stools in, 458
treatment of, 456-461
tympanites in, 458
Widal reaction in, 456
Ulceration at corner of mouth, 226
of hard palate, 225
of nasal septum a cause of nasal
hemorrhage, 224
of stomach, 184
Ulcerative stomatitis in typhoid fever,
457
Umbilical cord, care of stump, 26
hypertrophy of stump, 53
suppuration of stump, 26
hernia, 396
strapping for cure of, 396
polyp, 51
treatment of, 5 1
Umbilicus as portal of entry for infec-
tion, 49
Undescended testicle, 356
Unguentum hvdrargyrum in congeni-
tal syphilis, 388
Urea excretion, normal, and in nephri-
tis, 347
Uremia, convulsions in, 363
in acute nephritis, 346, 349
Urethra as portal of entry for pyogenic
bacteria, 49
calculi of, causing difficult micturi-
tion, 336
injury to, a cause of retention, 337
Urethritis, specific, 355
Urination, difficult and painful, 336
frequent, a precursor of bed-wetting,
335
Urine, 335
acidity of, amount and frequency,
factors influencing them, 335
as cause of difficult urination, 336
enuresis, 338
per day, 335
continence of, 336
devices for collecting, 336
examination at bedside, 315
in measles, 331
in jaundice, 437
in nephritis, 348
in scarlatina, 345
incontinence of, 336, 338
specific gravity of, 335
Urotropin in acute pyehtis, 352
in cystitis, 352
Urticaria, 407
Urticaria due to external irritation, 407
to internal causes, 407
following antitoxin, 307
giant, 387
low diet in, 408
treatment of, 408
Uvula, elongation of, ascause of persis-
tent cough, 285
Vaccination, age for, 484
complications of, 485
methods, 484
shield for, 485
virus for, 484
Vagina, portal of entry for pyogenic
organisms, 49
Vaginal discharge a deterrent to growth,
143
in nursery maids, 23
Vaginitis as cause of incontinence of
urine, 338
of retention of urine, 337
Valentine's beef-juice, 119
Vapo-cresoHne inhalations in pertussis,
325
Vaporizations in diphtheria, 309
Varicella, 332
care of skin in, 333
Ventral hernia, 397
Vesical calculus, 351
Vichy, 134
Visitors in sick-room, 274
Visual defects in epilepsy, 372
A'oice in retropharyngeal abscess, 242
Vomiting, 176
after adenoids, 429
causes for, 176
cyclic, 473
due to fat indigestion, 95
to too strong food, 88
during nursing, 67
g^vage in, 135, 136
in congenital stenosis of pylorus,
185, 186
in acute gastric indigestion, 178
gastro-intestinal infection, 192
in chronic gastritis, 179
in dilatation of the stomach, 183
in pertussis, belt for, 328
lavage in, 180
of blood, 183
persistent, a sign of peritonitis, 469
in congenital stenosis of pylorus,
185, 186
projectile, in congenital stenosis of
pylorus, 185
with sprue, 223
Von Jaksch, pseudoleukemic anemia
of, 438
Vulvar douching, 357
Vulvovaginitis, gonorrheal, 357, 358
simple, 357
597
Waking, time for, 25
Walker-Gordon Laboratory milk for
traveling, 116
Walking movements, 513
Warm air in asthma, 265
in meningitis, 374
pack in meningitis, 374
Washing child's mouth, 221, 222
in eczema, 403
mouth in sprue, 204
Water before nursing in fever, 133
function of, as a constituent of food,
60
in maternal nursing, 73
in morning, 184
fti nephritis, 343, 345
pressure of, in reduction of intussus-
ception, 21 1
Water-bed in decubitus, 413
Weaning, 71, 128
Weighing infants, 144
during nursing, 68, 75, 152
frequency, 31
Weight at birth, 31
chart, 32
initial loss of, 31
loss of, in the mother, contraindicat-
ing nursing, 7 1
normal amount of gain in, 32
of girls compared to boys, 32
stationary, a premonitory sign of
malnutrition, 144
in maternal nursing, 67
Well-water in country, 492
Wet compresses for laryngitis, 254
dressings of bichloride, 49
of boric acid, 49
sweeping in measles, 332
Wet-nurse after gastro-intestinal in-
fection, 195
age of, 73
diet of, 65
examination of, 74
in anemia of the bottle-fed, 439
in difficult feeding cases, 108
in gastritis, chronic, 179
Wet-nurse in marasmus, 151
in premature infants, 47
in stenosis of the pylorus, 1 86
in tetany, 367
selection of, 74
Wlieat crackers as cause of constipa-
tion, 171
jelly, formula for preparing, 123
Wheatena, when allowed, 131
Whey, 155
formula for preparing, 125
in dinicult feeding, 108
in premature infants, 47
mixtures, 96
Whisky, 277. vSee also Alcohol.
in erysipelas, 462
White l)read as cause of constipation,
171
precipitate ointment in ringworm of
scalp, 414
Whooping-cough. See also Pertussis.
Widal reaction, 456
Window-board, 25, 43, 57, 147, 258, 267,
274
Wine after second year, 132
Winter diarrhea predisposing to sum-
mer diarrhea, 160, 187
Woolen clothing after nephritis, 347
Worms as cause of convulsions, 363
as sign of intestinal toxemia, 162
symptoms of, 214
treatment of, 216
Worry, bad effect on lactation, 72
Written directions, 41
Yerb.\ Sant.a, a menstruum for quin-
in, 504
Yerberizine, a vehicle for quinin, 326,
504
Zinc oxid in eczema, 402, 403
ointment in eczema, 405
in intertrigo, 404
Zwieback, 457
when allowed, 129-132
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A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D.,
Professor of Obstetrics in the University of Pennsylvania. Handsome
octavo, 915 pages, with 767 illustrations, 40 of them in colors. Cloth,
$5.00 net; Sheep or Half Morocco, ;^6.50 net.
JUST ISSUED
Immediately on its publication this work took its place as the leading text-book
on the subject. Both in this country and in England it is recognized as the most
satisfactorily written and clearly illustrated work on obstetrics in the language.
The illustrations form one of the features of the book. They are numerous and
the most of them are original. In this edition the book has been thoroughly revised.
More attention has been given to the diseases of the genital organs associated with
or following childbirth. Many of the old illustrations have been replaced by better
ones, and there have been added a number entirely new. The work treats the
subject from a chnical standpoint.
OPINIONS OF THE MEDICAL PRESS
British Medical Journal
" The popularity of American text-books in this country is one of the features of recent
years. The popularity is probably chiefly due to the great superiority of their illustrations
over those of the English text-books. The illustrations in Dr. Hirst's volume are far more
numerous and far better executed, and therefore more instructive, than those commonly
fouHd in the works of writers on obstetrics in our own country."
Bulletin of Johns Hopkins Hospital
"The work is an admirable one in every sense of the word, concisely but comprehensively
written."
The Medical Record. New York
" The illustrations are numerous and are works of art, many of them appearing for the first
time. The author's style, though condensed, is singularly clear, so that it is never necessary
to re-read a sentence in order to grasp the meaning. As a true model of what a modern text-
book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without 3
rival."
DISEASES OE WOMEN.
HirstV
Diseases of Women
A Text=Book of Diseases of Women. By Barton Cooke Hirst,
M. D., Professor of Obstetrics, University of Pennsylvania ; Gynecolo-
gist to the Howard, the Orthopedic, and the Philadelphia Hospitals.
Octavo of 745 pages, with 701 original illustrations, many in colors.
Cloth, ^5.00 net; Half Morocco, $^.^0 net.
RECENTLY ISSUED NEW (2d) EDITION
WITH 701 ORIGINAL ILLUSTRATIONS
The new edition of this work has just been issued after a careful revision.
As diagnosis and treatment are of the greatest importance in considering diseases
of women, particular attention has been devoted to these divisions. To this end,
also, the work has been magnificently illuminated with 701 illustrations, for the
most part original photographs and water-colors of actual clinical cases accumu-
lated during the past fifteen years. The palliative treatment, as well as the
radical operative, is fully described, enabling the general practitioner to treat
many of his own patients v.ithout referring them to a specialist. An entire sec-
tion is devoted to a full description of all modern gynecologic operations, illumi-
nated and elucidated by numerous photographs. The author's extensive ex-
perience renders this work of unusual value.
OPINIONS OF THE MEDICAL PRESS
Medical Record, New York
"Its merits can be appreciated only by a careful perusal. . . . Nearly one hundred pages
are devoted to technic, this chapter being in some respects superior. to the descriptions in
many other text- boks."
Boston Medical and Surgical Journal
"The author has given special attention to diagnosis and treatment throughout the book,
and has produced a practical treatise which should be of the greatest value to the student, the
general practitioner, and the specialist."
Medical News, New York
"Office treatment is given a due amount of consideration, so that the work will be as
useful to the non-operator as to the specialist."
SAUNDERS' BOOKS ON
Penrose's
Diseases of Women
Fifth Revised Edition
A Text=Book of Diseases of Women. By Charles B. Penrose,
M. D., Ph. D., formerly Professor of Gynecology in the University of
Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc-
tavo volume of 550 pages, with 225 fine original illustrations. Cloth,
$3.75 net.
RECENTLY ISSUED
Regularly every year a new edition of this excellent text-book is called for,
and it appears to be in as great favor with physicians as with students. Indeed,
this book has taken its place as the ideal work for the general practitioner. The
author presents the best teaching of modern gynecology, untrammeled by anti-
quated ideas and methods. In every case the most modern and progressive
technique is adopted, and the main points are made clear by excellent illustra-
tions. The new edition has been carefully revised, much new matter has been
added, and a number of new original illustrations have been introduced. In its
revised form this volume continues to be an admirable exposition of the present
status of gynecologic practice.
PERSONAL AND PRESS OPINIONS
Howard A. Kelly. M. D..
Professor of Gynecology and Obstetrics. Johns Hopkins University, Baltimore.
" I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have
already recommended it to my class as THE BEST book."
E. E. Montgomery, M. D.,
Professor of Gynecology, Jefferson Medical College, Philadelphia.
" The copy of ' A Text-Book of Diseases of Women ' by Penrose, received to-day. I have
looked over it and admire it very much. I have no doubt it will have a large sale, as it justly
merits."
Bristol Medico-Chirurgical Journal
" This is an excellent work which goes straight to the mark. . . . The book may be takea
as a trustworthy exposition of modern gynecology."
G YNE CO LOG 1 ' A ND DBS TE TRIL S.
The American
Text-Book of Obstetrics*
Second Edition, Thoroughly Revised and Enlarged
The American Text=Book of Obstetrics. In two volumes. Edited
by Richard C. Norris, M.D., Assistant Professor of Obstetrics in the
University of Pennsylvania; Art Editor, Robert L. Dickinson, M.D.,
Assistant Obstetrician, Long Island College Hospital, N. Y. Two
handsome octavo volumes of about 6oo pages each; nearly 900 illus-
trations, including 49 colored and half-tone plates. Per volume :
Cloth, ;^3.50 net ; Sheep or Half Morocco, ^4.50 net.
RECENTLY ISSUED— IN TWO VOLUMES
Since the appearance of the first edition of this work many important advances
have been made in the science and art of obstetrics. The results of bacteriologic
and of chemicobiologic research as applied to the pathology of midwifery ; the wider
range of the surgery of pregnancy, labor, and of the puerperal period, embrace
new problems in obstetrics. In this new edition, therefore, a thorough and critical
revision was required, some of the chapters being entirely rewritten, and others
brought up to date by careful scrutiny. A number of new illustrations have been
added, and some that appeared in the first edition have been replaced by others
of greater excellence. By reason of these extensive additions the new edition
has been presented in two volumes, in order to facilitate ease in handling. The
pnce, however, remains unchanged.
PERSONAL AND PRESS OPINIONS
Alex. J. C. Skene, M. D.,
Late Professor of Gynecology, Lovg Island College Hospital, Brooklyn.
" Permit me to say that ' The American Text-Book of Obstetrics ' is the most magnificent
medical work that I have ever seen. I congratulate you and thank you for this superb work,
which alone is sufficient to place you first in the ranks of medical publishers."
Matthew D. Mann, M. D..
Professor of Obstetrics and Gynecology in the University of Buffalo.
" I like it exceedingly and have recommended the first volume as a text-book for oui
sophomore class. It is certainly a most excellent work. I know of none better."
American Journal of the Medical Sciences
" As an authority, as a book of reference, as a ' working book ' for the student or practi
tioner, we commend it because we believe there is no better."
SAUNDERS' BOOKS ON
GET ik • THE NEW
THE BEST /\ m 6 r 1 C Si n standard
Illustrated Dictionary
Just Issued— New(4th) Edition
The American Illustrated Medical Dictionary. A new and com-
plete dictionary of the terms used in Medicine, Surgery, Dentistry,
Pharmacy, Chemistry, and kindred branches; with over lOO new and
elaborate tables and many handsome illustrations. By W. A. Newman
DoRLAND, M. D., Editor of " The American Pocket Medical Diction-
ary." Large octavo, nearly 850 pages, bound in full flexible leather.
Price, $^.SO net; with thumb index, ^$5.00 net.
Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest
Possible Cost
WITH 2000 NEW TERMS
The immediate success of this work is due to the special features that distin-
guish it from other books of its kind. It gives a maximum of matter in a mini-
mum space and at the lowest possible cost. Though it is practically unabridged,
yet by the use of thin bible paper and flexible morocco binding it is only 1 3^
inches thick. The result is a truly luxurious specimen of book-making. In this
new edition the book has been thoroughly revised, and upward of fifteen hundred
new terms that have appeared in recent medical literature have been added, thus
bringing the book absolutely up to date. The book contains hundreds of terms
not to be found in any other dictionary, over 100 original tables, and many hand-
some illustrations, a number in colors.
PERSONAL OPINIONS
Howard A. Kelly, M. D..
Professor of Gynecology, Johns Hopkins University, Baltimore.
" Dr. Borland's dictionary is admirable. It is so well gotten up and of such convenient
si»e. No errors have been found in my use of it."
J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)
Professor of Surgery^ Harvard Medical School.
" I regard it as a valuable aid to my medical literary work. It is very complete and of
convenient size to handle comfortably. I use it in preference to any other."
GYNECOLOGY AND OBSTETRICS.
Garrigues*
Diseases of Women
Third Edition, Thoroughly Revised
A Text-Book of Diseases of Women. By Henry J. Garrigues,
A. M., M. D., Gynecologist to St. Mark's Hospital and to the German
Dispensary, New York City, Handsome octavo, 756 pages, with 367
engravings and colored plates. Cloth, ^4.50 net; Sheep or Half
Morocco, $6.00 net.
The first two editions of this work met with a most appreciative reception by
the medical profession both in this country^ and abroad. In this edition '.he entire
work has been carefully and thoroughly revised, and considerable new matter
added, bringing the work precisely down to date. Many new illustrations have been
introduced, thus greatly increasing the value of the book both as a text-book and
book of reference.
Thad. A. Reamy. M. D. , Professor of Clinical Gynecology, Medical College of Ohio.
•One of the best text-books for students and practitioners which has been published in the
English language ; it is condensed, clear, and comprehensive. The profound learning and
great clinical experience of the distinguished author find expression in this book.
American
Text-Book of Gynecology
American Text-Book of Gynecology: Medical and Surgical.
Edited by J. M. Baldy, M. D., Professor of Gynecology, Philadelphia
Polyclinic. Imperial octavo of 718 pages, with 341 text-illustrations
and 38 plates. Cloth, s6.oo net; Half Morocco, $7.50 net.
SECOND REVISED EDITION
This volume is thoroughly practical in its teachings, and is intended to be a
working text-book for physicians and students. Many of the most important
subjects are considered from an entirely new standpoint, and are grouped together
in a manner somewhat foreign to the accepted custom.
Boston Medical and Surgical Journal
■■The most complete exponent of gynecology which we have. No subject seems to have
been neglected."
SAUNDERS' BOOKS ON
Dorland*s
Modern Obstetrics
Modern Obstetrics: General and Operative. By W. A. Newman
Borland, A. M., M. D., Assistant Instructor in Obstetrics, Univer-
sity of Pennsylvania; Associate in Gynecology in the Philadelphia
Polyclinic. Handsome octavo volume of 797 pages, with 201 illustra-
tions. Cloth, $4.00 net.
Second Edition, Revised and Greatly Enlarged
In this edition the book has been entirely rewritten and very greatly enlarged.
Amongthe new subjects introduced are the surgical treatment of puerperal sepsis,
infant mortahty, placental transmission of diseases, serum-therapy of puerperal
sepsis, etc. By new illustrations the text has been elucidated, and the subject pre-
sented in a most instructive and acceptable form.
Journal of the American Medical Association
" This work deserves commendation, and that it has received what it deserves at the hands
of the profession is attested by the fact that a second edition is called for within such a short
time. Especially deserving of praise is the chapter on puerperal sepsis."
Davis* Obstetric and
Gynecologic Nursing(
Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M.,
M. D., Professor of Obstetrics in the Jefferson Medical College and
Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia
Hospital. i2mo of 400 pages, illustrated. Buckram, $1.75 net.
RECENTLY ISSUED— SECOND REVISED EDITION
Obstetric nursing demands some knowledge of natural pregnancy, and gyne-
cologic nursing, really a branch of surgical nursing, requires special instruction
and training. This volume presents this information in the most convenient
form. This second edition has been very carefully revised throughout, bringing
the subject down to date.
The Lancet, London
" Not only nurses, but even newly qualified medical men, would learn a great deal by a
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom-
mend."
GYNECOLOGY AND OBSTETRICS. 13
Schaffer and Edgar's
Labor and Operative Obstetrics
Atlas and Epitome of Labor and Operative Obstetrics. By Dr.
O. Schaffer, of Heidelberg. From the Fifth Revised and Enlarged
German Edition. Edited, with additions, by J. Clifton Edgar, M. D.,
Professor of Obstetrics and Clinical Midwifery, Cornell University Medi-
cal School, New York. With 14 lithographic plates in colors, 139 other
illustration's, and in pages of text. Cloth, ;^2.oo net. /;/ Saunders'
Hand-Atlas Series.
This book presents the act of parturition and the various obstetric operations
in a series of easily understood illustrations, accompanied by a text treating the
subject from a practical standpoint. The author has added many accurate repre-
sentations of manipulations and conditions never before clearly illustrated.
American Medicine
■• The method of presenting obstetric operations is admirable. The drawings, representing
original work, have the commendable merit of illustrating instead of confusing. It would be
d.fficult to find one hundred pages in better form or containing more practical points for
students or practitioners." ^^^^
Schaffer and Edgar's
Obstetric Diagnosis and Treatment
Atlas and Epitome of Obstetric Diagnosis and Treatment. By
Dr. O. Schaffer, of Heidelberg. From the Seeond Revised German
Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor
of Obstetrics and Clinical Midwifery, Cornell University Medical School,
N. Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315
pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series,
This book treats particularly of obstetric operations, and, besides the wealth
of beautiful lithographic illustrations, contains an extensive text of great value.
This text deals with the practical, cUnical side of the subject. The symptoma-
tology and diagnosis are discussed with all necessary fullness, and the indications
for treatment are definite and complete.
New York Medical Journal
•■ The illustrations are admirably executed, as they are in all of these atlases, and the text
can safely be commended, not only as elucidatory of the plates, but as expounding the scien-
tific midwifery of to-day."
SAUNDERS' BOOKS ON
Schaffer and Norris*
Gynecology
Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of
Heidelberg. From the Second Revised and Enlarged German Edition.
Edited, with additions, by Richard C. Norris, A. M., M. D., Gynecolo-
gist to Methodist Episcopal and Philadelphia Hospitals. With 207
colored figures on 90 plates, 65 text-cuts, and 308 pages of text.
Cloth, ;^3.50 net. In Saunders' Hajid- Atlas Scries.
The value of this atlas to the medical student and to the general practitioner
will be found not only in the concise explanatory text, but especially in the illus-
trations. The large number of colored plates, reproducing the appearance of
fresh specimens, give an accurate mental picture and a knowledge of the changes
induced by disease of the pelvic organs that cannot be obtained from mere
description.
American Journal of the Medical Sciences
" Of the illustrations it is difficult to speak in too high terms of approval. They are so
clear and true to nature that the accompanying explanations are almost superfluous. We
commend it most earnestly."
Galbraith*s
Four Epochs of Woman's Life
Second Revised Edition — Recently Issued
The Four Epochs of Woman's Life : A Study in Hygiene. By
Anna M. Galbraith, M. D., Fellow of the New York Academy of
Medicine, etc. With an Introductory Note by John H. Musser,
M. D., Professor of Clinical Medicine, University of Pennsylvania.
i2mo of 247 pages. Cloth, ;^i.50 net.
MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE
In this instructive work are stated, in a modest, pleasing, and conclusive manner,
those truths of which every woman should have a thorough knowledge. Written,
as it is, for the laity, the subject is discussed in language readily grasped even by
those most unfamiliar with medical subjects.
Birmingham Medical Review, England
" We do not as a rule care for medical books written for the instruction of the public. But
we must admit that the advice in Dr. Galbraith's work is in the mam wise and wholesome."
GYNECOLOGY AND OBSTETRICS.
Schaffer and Webster's
Operative Gynecology
Atlas and Epitome of Operative Gynecology. By Dr. O. Schaf-
fer, of Heidelberg. Edited, with additions, by J. Clarence Webster,
M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in
Rush Medical College, in affiliation with the University of Chicago.
42 colored lithographic plates, many text-cuts, a number in colors, and
138 pages of text. In Smdidcrs' Hand-Atlas Scries. Cloth, $3.00 net.
RECENTLY ISSUED
Much patient endeavor has been expended by the author, the artist, and the
lithographer in the preparation of the plates of this atlas. They are based on
hundreds of photographs taken from nature, and illustrate most faithfully the
various surgical situations. Dr. Schaffer has made a specialty of demonstrating
by illustrations.
Medical Record, New York
" The volume should prove most helpful to students and others in grasping details usually
to be acquired only in the amphitheater itself."
De Lee's
Obstetrics for Nurses
Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of
Obstetrics in the Northwestern University Medical School ; Lecturer
in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook
County, and Chicago Lying-in Hospitals, i 2mo \olume of 460 pages,
fully illustrated. Cloth, $2.50 net.
JUST ISSUED-riEW f2nd) EDITION
While Dr. De Lee has written his work especially for nurses, yet the prac-
titioner will find it useful and instructive, since the duties of a nurse often devolve
upon him in the early years of his practice. The illustrations are nearly all
original, and represent photographs taken from actual scenes. The text is the
result of the author's eight years' experience in lecturing to the nurses of five
different training schools.
J. Clifton Edgar. M. D.,
Pra/essor of Obstetrics and Clinical Midwifery, Cornell University . A-ew York.
" It is far and away the best that has come to my notice, and I shall take great pleasure in
recommending it to mv nurses, and students as well,"
i6 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS.
American Pocket Dictionary ^''*'^ ""'^'TusuS
The American Pocket Medical Dictionary. Edited by W.
A. Newman Borland, A.M., M. D., Assistant Obstetrician to the
Hospital of the University of Pennsylvania ; Fellow of the American
Academy of Medicine. Over 550 pages. Full leather, limp, with
gold edges, ^i.oo net ; with patent thumb index, $1.2^ net.
James W. Holland. M. D.,
Professor of Medical Chemistry and Toxicology at the Jefferson Medical College,
Philadelphia.
" I am struck at once with admiration at the compact size and attractive exterior. I
can recommend it to our students without reserve."
Recently Issued
Cra£(in*s Gynecology. New i6th) Edition
PLssentials of Gynecology. By Edwin B. Cragin, M. D.,
Professor of Obstetrics, College of Physicians and Surgeons, New
York. Crown octavo, 215 pages, 62 illustrations. Cloth, $1.00
net. /// Saunders' Question- Compend Series.
The Medical Record, New York
" A handy volume and a distinct improvement of students' compends in general.
No author who was not himself a practical gynecologist could have consulted the
student's needs so thoroughly as Dr. Cragin has done."
Boisliniere*s Obstetric Accidents, Emer|»encies, and
Operations
Obstetric Accidents, Emergencies, and Operations. By
the late L. Ch. Boisliniere, M. D., Emeritus Professor of Ob-
stetrics, St. Louis Medical College ; Consulting Physician, St. Louis
Female Hospital. 381 pages, illustrated. Cloth, ^2.00 net.
British Medical Journal
" It is clearly and concisely written, and is evidently the work of a teacher and practi-
tioner of large experience, its merit lies in the judgment which comes from experience."
AshtOn*S Obstetrics. Recently Issued— New (6th) Edition
Essentials of Obstetrics. By W. Easterly Ashton, M.D.,
Professor of Gynecology in the Medico-Chirurgical College, Phila-
delphia. Crown octavo, 256 pages, 75 illustrations. Cloth, ;$i.oo
net. In Saunders' Question- Compend Series.
Southern Practitioner
" An excellent little volume ccataining correct and practical knowledge. An admir-
able compend, and the best condensation we have seen."
Barton and Wells' Medical Thesaurus Recently issued
A Thesaurus of Medical Words and Phrases. By Wilfred
M. Barton, M. D., As.sistant to Professor of Materia Medica and
Therapeutics, Georgetown University, Washington, D. C. ; and
Walter A. Wells, M. D., Demonstrator of Laryngology, George-
town University, Washington, D. C. l2mo of 534 pages. Flex-
ible leather, 1^2.50 net ; with thumb index, ^3.00 net.
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